| DETERMINATION OF REVIEW PANEL | |
| CITATION: | AAI Limited t/as GIO v Dell (No 1) [2024] NSWPICMP 216 |
| CLAIMANT: | Jeremy Dell |
| INSURER: | AAI Limited t/as GIO |
| REVIEW PANEL | |
| MEMBER: | Belinda Cassidy |
| MEDICAL ASSESSOR: | Michael Couch |
| MEDICAL ASSESSOR: | John O’Neil |
| DATE OF DECISION: | 9 April 2024 |
| CATCHWORDS: | MOTOR ACCIDENTS – Motor Accidents Compensation Act 1999; insurer’s application for review of Medical Assessor (MA) Dixon’s whole person impairment (WPI) assessment of a neck and lower back injury; claimant had a 2012 lower back injury and developed cauda equina syndrome partly relieved by surgery and removal of sequestrated disc fragment; claimant riding his bicycle on 2 June 2017 when hit by a car and thrown off his bike onto the bonnet and down onto the road; claimant fractured his sacrum and developed neck pain which resolved after a few months and lower back pain which he said worsened his cauda equina symptoms; claimant had further surgery in August 2018 to remove a further piece of herniated disc at the same level as previously; insurer alleged only injury was fractured sacrum and that the claimant’s worsened cauda equina symptoms was a result of a deterioration of the original condition; insurer relied on a more than six-month gap in the records between the accident and the development of worsening symptoms; Held – Panel found the mechanism of the accident could have caused or contributed to the worsening of the claimant’s cauda equina and that it did cause or contribute to the worsening of the syndrome; the Panel accepted the claimant’s explanation for the absence of symptoms; fractured sacrum assessed at 0%; while radiology immediately after the accident showed fracture was minimally displaced, there was no subsequent evidence suggesting the fracture remained displaced; neck injury had resolved and attracted no impairment; lower back injury assessed on basis there was a previous (2018) surgery with no radiculopathy DRE IV less pre-existing impairment of DRE II on same basis (2012 surgery with no radiculopathy); WPI 10%; impairment to bladder, bowel and sexual functioning caused by the cauda equina syndrome assessed by others and also under review and considered; combined certification of greater than 10% issued; MA Dixon’s assessment of 10% WPI confirmed. |
| DETERMINATIONS MADE: | CERTIFICATE OF DETERMINATION Issued under Part 3.4 of the Motor Accidents Compensation Act 1999 The Review Panel: 1. Confirms the certificate issued by Medical Assessor Dixon on 29 September 2022. 2. In answer to the statutory question of whether the degree of Mr Dell’s permanent impairment as a result of the injuries caused by the motor accident is greater than 10%, certifies that (a) the Panel’s finding of a 15% impairment for bowel dysfunction in the related proceedings R-M22054/23-52-1; (b) the finding in this decision of a 10% impairment for musculoskeletal injuries, and (c) the Panel’s finding of a 5% impairment for bladder and sexual dysfunction in the related proceedings R-M10422780/21-52-1. |
STATEMENT OF REASONS
INTRODUCTION
Jeremy Dell was involved in a motor accident on 2 June 2017. Mr Dell was at the time, 42 years of age. He is now 48.
Mr Dell was riding his bicycle when he was hit from behind by a vehicle insured with GIO.
Mr Dell says he injured his cervical and lumbosacral spine in the accident and aggravated a pre-existing cauda equina syndrome. Mr Dell made a claim for damages against GIO and the Panel understands GIO has accepted liability for the claim.
A medical dispute about the degree of the claimant’s whole person impairment (WPI) arose in connection with that claim and on 12 June 2021 Mr Dell referred that dispute to the Personal Injury Commission (Commission) for assessment.
The Commission arranged medical assessments in respect of the injuries alleged by the claimant in order to determine that dispute as follows:
(a) musculoskeletal injuries including fractured sacrum – Medical Assessor Dixon;
(b) bladder and sexual dysfunction arising from the pre-existing cauda equina syndrome – Medical Assessor Korbel;
(c) bowel dysfunction arising from the pre-existing cauda equina syndrome – Medical Assessor Garvey, and
(d) psychological or psychiatric injury – Medical Assessor Suman. The Panel understands this assessment is not under review.
Medical Assessment by Medical Assessor Dixon
On 29 September 2022, Medical Assessor Dixon determined that Mr Dell did not have a WPI of greater than 10% (the WPI found was 10% exactly).
Mr Dell lodged an application with the Commission seeking a review of the Medical Assessor’s decision (proceedings numbered R-M10542161/22).
On 20 December 2022, the President’s delegate Ms Baba determined there was reasonable cause to suspect a material error in the assessment and allowed the Review to proceed.
On 16 February 2023, the President convened a Panel comprising Member Cassidy and Medical Assessors Stubbs and Couch to conduct the Review. In due course that Panel was reconvened to comprise Medical Assessors O’Neill and Couch with Member Cassidy.
Medical Assessment by Medical Assessor Korbel
On 3 November 2022, Medical Assessor Korbel determined that Mr Dell did not have a WPI of greater than 10% (the WPI found was 5%).
GIO lodged an application with the Commission seeking a review of Medical Assessor Korbel’s decision (proceedings number R-M10422780/21-52-1).
On 18 August 2023, the President’s delegate Ms Jones determined there was reasonable cause to suspect a material error in the assessment and allowed the Review to proceed.
On 24 October 2023, the President convened a Panel comprising Member Cassidy and Medical Assessors O’Neill and Couch to conduct the Review.
Medical Assessment by Medical Assessor Garvey
On 11 September 2023, Medical Assessor Garvey determine that Mr Dell had a WPI of 30% which is greater than 10%.
GIO lodged an application with the Commission seeking a review of Medical Assessor Garvey’s decision (proceedings numbered R-M10542161/22).
On 16 January 2024, the President’s delegate Ms Brittliff determined there was reasonable cause to suspect a material error in the assessment and allowed the Review to proceed.
On 17 January 2024, the President convened a Panel comprising Member Cassidy and Medical Assessors O’Neill and Couch to conduct the Review.
The current proceedings
Each of the three assessments under review arose out of the referral of a single dispute to the Commission and the members of the Panel in each review are the same. The Panel determined to hear the three matters together.
The three review proceedings were each commenced separately, at different times and were given a separate matter number by the Commission. The three proceedings were not consolidated under Rule 64 of the Personal Injury Commission Rules 2021.
The Panel is therefore of the view that a separate decision will need to be issued in each matter and a combined certificate will also be issued pursuant to s 63(5).
LEGISLATIVE FRAMEWORK
Mr Dell’s claim and entitlements to compensation are governed by the provisions of the Motor Accident Compensation Act 1999 (the MAC Act).
Damages for non-economic loss are provided for in Part 5.3 of the MAC Act but are limited and regulated. For example, non-economic loss damages are limited to a maximum amount in accordance with s 134[1] and entitlement to those damages is restricted by s 131 to persons who have a greater than 10% WPI as a result of the injuries sustained in the accident.
[1] The current maximum as of October 2023 is $620,000.
Permanent impairment assessment
Permanent impairment is to be assessed in accordance with the Motor Accident Permanent Impairment Guidelines (the Guidelines)[2] which are largely based on the American Medical Association’s Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA4 Guides).
[2] Section 133. The current version of the Guidelines is Version 1 which is effective from 30 November 2017.
In the Supreme Court decision of Nguyen v Motor Accidents Authority of New South Wales and Anor[3] it was found that if an injury to one part of the body (in the Nguyen case it was the neck) caused an impairment to the functioning of another part of the body (in that case the shoulders), that impairment must be assessed, and its value included in the determination of the claimant’s total WPI. Therefore, if a spinal cord or nerve injury caused impairment to the functioning of the bladder, bowel and sexual organs, those impairments must be assessed and combined and added to the WPI assessment for the injured spine.
[3] [2011] NSWSC 351.
Due to the nature of the impairment alleged by Mr Dell to be re-assessed by this Panel, Chapter 3, the musculoskeletal chapter is relevant to the assessment.
Dispute resolution
If there is a dispute about the degree of the claimant’s permanent impairment, damages for non-economic loss cannot be awarded and disputes must be referred to a Medical Assessor for determination.[4]
[4] See s 132 and s 44(1)(c) of the MAC Act.
Part 3.4 of the MAC Act provides for medical assessments by the Commission including provisions relevant to an original medical assessment such as those of Medical Assessors Dixon, Korbel and Garvey, further medical assessments and the review of medical assessments by this Panel.[5]
[5] Sections 61, 62 and 63 of the MAC Act.
ASSESSMENT UNDER REVIEW
Medical Assessor Dixon examined the claimant on 29 September 2022 and issued his decision on 6 October 2022. He notes at [2] that he was asked to assess the following injuries:
(a) lumbar spine – blunt injury causing neck and back pain as well as fracture of the vertical cortex of S3, and
(b) cervical spine – blunt injury causing neck pain.
The claimant is an accountant and Medical Assessor Dixon outlines his career noting the claimant was currently working four days a week alternating “between sitting and standing … because of residual low back pain”.
Medical Assessor Dixon records the claimant’s medical history as including:
(a) Guillain Barre syndrome in May 2008 with bilateral leg weakness, paraesthesia in the arms and legs and headache with muscular pain and that he recovered from this;
(b) right shoulder pain in 2012 with investigations and pathology found;
(c) an incident on a bike in 2012 investigated with the results of degenerative disc disease with symptoms in the lower back and buttock. The claimant reported bladder, bowel and erectile dysfunction following this incident. Mr Dell had a L5/S1 right sided discectomy and decompression in June 2012, and
(d) cauda equina syndrome investigated in August 2012 which was still causing some symptoms at the time of the accident.
The claimant gave a history of being knocked off his bike, onto the bonnet of a car and then falling onto the road. He was transported to John Hunter Hospital and discharged the same day, attending his general practitioner (GP) two weeks later.
The claimant told Medical Assessor Dixon that his neck injury had settled and that he had no paraesthesia in the upper limbs and no pain or stiffness in the cervical region.
The claimant did report residual stiffness in his lower back aggravated by bending and stooping such as weeding the garden, foot care and heavy cleaning. He had pain in his hamstrings and persisting perianal loss of sensation in the perineum. There was no report of sciatica, but he reported altered sensation in the soles of both feet.
The claimant reported no change in his bladder function since the accident, but his sex life had ceased due to insufficient sensation, and he now cannot maintain an erection. He also reported deterioration of his bowel incontinence.
He was taking an antidepressant (Pristiq) and anti-inflammatory (Mobic) and Cialis for his sexual dysfunction.
On examination of Mr Dell’s neck, Medical Assessor Dixon recorded a full range of cervical spine movements, there were no neurological deficits in the upper limbs and no guarding, dysmetria or non-verifiable radicular complaints.
In the lumbar spine there was stiffness and asymmetrical loss of range of motion. There was also non-verifiable radicular complaint of sensory alteration to his soles and an absent hamstring jerk which the Medical Assessor said was consistent with an L5/S1 radiculopathy.
Medical Assessor Dixon’s diagnosis was:
“The claimant has had a severe low back strain injury with fracture of S3 of the sacrum, ventral cortex and recurrent L5/S1 disc protrusion as a result of direct blunt trauma when his back hit the bonnet of the car and then he was thrown onto the road. He had transient neck strain injury following blunt trauma to his neck which has settled.”
Medical Assessor Dixon’s finding on impairment was:
“The claimant’s whole person impairment for the lumbosacral spine where he has had a known back injury with fracture of the sacrum at S3 and discal instability at L5/S1 with subsequent disc prolapse requiring discectomy with residual L5/S1 radiculopathy is DRE Category III, 10% WPI. There is no assessable WPI for the S3 sacral fracture.
His surgical scar has healed reasonably and does not concern the claimant.
His urological assessment remains unchanged.
The claimant reports there has been deterioration in his bowel incontinence by some 40% and because of his now inactive sex life, despite taking Cialis for his sexual dysfunction, this appears to have deteriorated. These have not been included in his musculoskeletal assessment.”
Medical Assessor Dixon assessed the lumbar spine at 10% and made no deduction for any pre-existing impairment.
ISSUES FOR DETERMINATION
Insurer’s submissions in support of the application for review
The insurer raises the Medical Assessor’s apparent failure to consider causation as the substantial issue in respect of the review. The insurer says at [6]:
“Four doctors had assessed the claimant with substantial impairment in the lumbar spine prior to the subject accident. Specifically, Dr Ghobrial and Dr Kalnins assessed DRE category III impairment of the lumbar spine as a consequence of L5/S1 disc extrusion resulting in cauda equina syndrome.”
The insurer notes that Medical Assessor Dixon found no new pathology in the L5/S1 disc and a “minimally displaced” S3 fracture of the vertical cortex but gave no reasons why he accepted the whole of the claimant’s current presentation was caused by the motor accident with no contribution from the previous bicycle accident.
The insurer also notes at [30] that Medical Assessor Dixon suggested the insurer was of the view the claimant’s WPI was limited to 10% however the insurer said it has never advanced that argument.
Claimant’s submissions in support of the application for review
The claimant submits that cl 1.31 of the Guidelines requires there to be a deduction for a pre-existing impairment if there is symptomatic impairment in the same region at the time of the accident.
The claimant concedes at [2(c)] there was a pre-existing lumbar spine condition but notes the reports relied on by the insurer were dated 3 – 4 years before the current accident.
The claimant says at [2(e)] the claimant had no back pain before the accident and at [2(f)] that before the accident his lumbar spine symptoms were “well controlled” and at [2(g)] that in the 20 months before the accident the GP notes reveal no symptoms.
The claimant also asserts at [2(j)] that the medical reports from before the accident were assessments of impairment undertaken in the workers compensation scheme and not in accordance with motor accident requirements.
The claimant also says that Medical Assessor Dixon undertook an assessment of the claimant’s orthopaedic lumbar spine injuries and not cauda equina which is not assessable as an orthopaedic injury.
Procedural matters
There have been a number of procedural directions issued and deferrals of the various Reviews associated with the gathering together of the three separate proceedings. Suffice to say the Panel has now been charged with the Review of all three of the medical assessments that have been undertaken in respect of Mr Dell’s WPI.
The Panel resolved to hear all three review proceedings together and determine the matters together noting the common issue of causation.
On 24 January 2024, the Panel requested the parties provide:
(a) submissions as to causation and impairment assessment, and
(b) a joint bundle of documents.
A preliminary conference was held with the legal representatives of the parties and Member Cassidy on 7 February 2024 to discuss the directions and ensure compliance.
Insurer’s final submissions
The insurer says that the only injuries sustained by the claimant in the current accident was a fractured sacrum and grazes.
The insurer says that the claimant had a pre-existing cauda equina syndrome from a previous bicycle accident in 2012 and that the claimant’s recent laminectomy was a progression of his pre-existing condition or a spontaneous rupture of the previously injured disc.
The insurer notes that after the accident the claimant was taken to John Hunter Hospital and was discharged the next day. He saw his doctor 14 days later and returned to work. Ten days after that the claimant complained of pins and needs in his right arm. A Workcover certificate was completed in relation to his 2012 accident.
The insurer notes the claimant continued to complain of lower back pain but remained at work. The insurer says there is then a considerable absence of complaints until
January 2018 when the claimant had increased lumbar pain, bowel and bladder symptoms. On 16 April 2018 he reported “a CTP problem” to his doctor and worsening pain with activity. An MRI undertaken on 19 April 2018 showed a disc herniation at L5/S1 impinging the descending nerve roots.
The claimant attended John Hunter Hospital on 29 August 2018 reporting increasing lower back pain, urinary and bowel issues.
The insurer says at [78]:
“Whilst the insurer notes the plaintiff attributes the decline in his condition to the subject accident, the insurer submits this position is not supported by the objective evidence, including the radiological evidence and the absence of complaint of injury or any worsening of the plaintiff’s condition at the time of his attendance on his general practitioner contemporaneous to the subject accident.”
The insurer also says the S3 fracture has no causal relationship to the L5/S1 disc protrusion and cauda equina and did not cause or contribute to the worsening of the claimant’s bladder, bowel and sexual functioning.
The insurer also points to cl 1.31 of the Guidelines and says there is objective evidence of pre-existing symptomatic impairment in the pre-accident workers compensation assessments which must be taken into account.
The insurer submits the assessment should be:
(a) lumbar spine – 0% WPI (pre-existing 13%), and
(b) cervical spine – no impairment.
Claimant’s final submissions
The claimant documents his 2012 accident and the treatment he received after it, suggesting that the records indicate the claimant’s back pain had improved by September 2015 and that although he had some issues with bladder and sexual function there is no record of any medical treatment or investigation in 2016 or for the first six months of 2017 before the claimant’s current accident.
The claimant notes the deterioration commenced on 18 January 2018 with no obvious trigger at that time and that by 16 April 2018 the claimant’s bowel and bladder function had deteriorated and that by 27 August 2018 his pain levels had deteriorated.
The claimant notes the test of causation specified in the Guidelines is whether the motor accident caused or materially contributed to the injury. The accident does not need to be the only cause but a contributing cause. The claimant says the car accident is a cause or material contribution to the claimant’s decline and the worsening of his cauda equina syndrome.
Claimant’s application to admit late documents
On 7 March 2023, the day before the medical re-examination, the claimant lodged an application to admit additional documents not attached to the reply and not attached to the claimant’s final bundle uploaded to the portal in accordance with the Panel’s directions. The additional documents are additional submissions, two photographs of the scene of the collision and a report from Dr Cleaver.
The report from Dr Cleaver follows his file review and does not appear to be a result of a medical examination.[6] He was reporting on the causation connection between the accident and the sudden onset of worsening symptoms from January to August 2018. The claimant’s submissions requested the Panel defer the Review until Dr Cleaver had the opportunity of obtaining the “entire radiological portfolio” that he requests in his report.
[6] This is not entirely clear. The cover of the report indicates the report was written following a file review, but page three of the report refers to a letter of 7 March 2023 and that “the documents accompanying your letter have been perused” and that he has “examined” Mr Dell.
The insurer objected in strong terms to the inclusion of this material although not directly addressing the request for the Panel to defer its decision.
The Panel notes that Dr Cleaver says his report was written following a request for a report from the claimant’s solicitors dated 7 March 2023, a year previously. There is no explanation why it took Dr Cleaver a year to prepare the rather short report and what efforts had been made by the claimant’s solicitor to chase it up in the interim.
The Panel will not admit the documents into evidence and will not defer its determination of the current proceedings for the following reasons:
(a) the insurer objects;
(b) the accident the subject of this claim occurred nearly seven years ago;
(c) the current proceedings have been on foot for some time;
(d) both parties have made final submissions and filed final bundles;
(e) Mr Dell has been re-examined;
(f) one of the objects of the MAC Act is “to encourage the early resolution of compensation claims” and the admission of the documents would result in the deferral of the Review to enable the insurer to consider its position and possibly request additional medical evidence;
(g) noting Dr Cleaver took 12 months to respond to the claimant’s solicitor’s letter requesting the report, it is possible he might take a further considerable period to provide his final report, and
(h) the Panel would not be assisted by a medico-legal opinion on causation. The Panel is required to make its own decision about causation and is not required to choose between competing experts.[7]
The documents attached to the claimant’s application to admit late documents filed with the Commission on 7 March 2024 have not been admitted into evidence and will not be considered.
On 26 March 2024, after the medical re-examination, the claimant’s solicitor lodged two files in the portal apparently containing digital radiological images. The medical members of the Panel were not able to view the images.
The medical members of the Panel considered the images were unlikely to assist the Panel in its deliberations concerning the cauda equina syndrome and associated impairments. The radiology would assist the panel if it was up to date imaging of the claimant’s sacrum showing, for example, a healed but displaced fracture. If that were the case the claimant would have a 5% higher degree of impairment which is not critical to the outcome of the dispute about WPI in the light of the Panel’s findings in the other reviews.
The Panel does not propose in the circumstances to hold up the finalisation of the three Reviews and will not allow these images into evidence.
REVIEW OF THE EVIDENCE
Background
The insurer lodged a joint bundle comprising over 3,700 pages. Two thousand of those pages are the workers compensation file relevant to the claimant’s 2012 injury.
Justice Basten in Rahman v Insurance Australia Ltd t/as NRMA Insurance[8] said at [63]:
“The Court of Appeal has, on more than one occasion, remarked on the volume of material which is routinely provided to medical assessors under the Act and under workers’ compensation legislation. (Providing it to the court is also commonplace, though misconceived.) Not only is there no general law principle requiring an assessor to refer in reasons accompanying a certificate to all the documentation to which he or she has had access, but rather, the function of the assessor is inconsistent with any such obligation. A judicial officer is not required to refer to each piece of evidence in a judgment determining the resolution of a dispute to which expert opinion is critical. As noted above, the function of the medical assessor is quite different. The assessor is not resolving a dispute between experts, but forming his or her expert opinion. The application of expertise permits (and indeed requires) the assessor to be discriminating as to that material which he or she considers significant and that which may be disregarded or given little weight. There is no requirement to identify material falling into the latter category, nor to justify its exclusion from consideration.”
[8] [2022] NSWSC 1079.
The Panel has considered the documentation in the bundle but will not detail each and every page of each and every document in that bundle. For example, the parties have included in the joint bundle the full hospital records from after the accident and for the claimant’s lumbar disc surgery at Hunter Valley Private Hospital. As there is no dispute that the claimant was admitted to hospital and did have the surgery, the Panel does not consider it necessary to summarise the more than 300 pages of hospital notes relating to that admission.
Claim form and claim documents
The claim form is dated 8 June 2017.[9] At question 23 the claimant lists the following injuries:
(a) back fracture (sacrum lower back);
(b) multiple abrasions left leg;
(c) neck pain;
(d) back pain lower back, and
(e) bruising buttocks.
[9] Page 69 of the joint bundle.
Dr Barnett of Marketown Health completed the medical certificate for the claim form on
16 June 2017.[10] He examined the claimant on that date, certified him unfit to work from a week after 2 June 2017 and noted he had been the claimant’s GP for 10 years.
[10] Page 208 of the joint bundle.
Dr Barnett records that the claimant was seen at hospital with a fractured sacrum and grazes and bruises.
The workers compensation file suggests that the claimant settled his lump sum entitlements in May 2014 and no medical assessment occurred in the Workers Compensation Commission (or this Commission) in respect of that claim.
Previous conditions
There is Hunter New England Hospital documentation[11] noting the claimant’s treatment in 2008 for Guillain Barre Syndrome following a virus which caused bilateral leg weakness, pins and needles in his arms and legs, headaches and muscular aches.
[11] Page 80 of the joint bundle.
2012 accident records
Dr Barnett’s records include a one-page summary of the development of shoulder pain and lower back issues from 21 April 2012 to 19 June 2012.[12] The shoulder problems were investigated by Dr Brindley and are set out in a letter from him to Dr Barnett dated
12 June 2012.[13]
[12] Page 85 of the joint bundle.
[13] Page 86 of the joint bundle.
Dr Barnett referred the claimant to Dr Christie on 21 June 2012[14] noting the claimant developed back pain whilst exercising at the gym and felt more pain when cycling home. His pain developed further with an acute exacerbation of his symptoms with lumbar back pain radiating down the buttocks and behind the legs with numbness and cramping sensations.
[14] Page 89 of the joint bundle.
There is an operation report from Dr Christie confirming surgery was done on 23 June 2012 “to remove an extremely large piece of disc” at L5/S1.[15] This was done following a history of progressive lower back pain and sciatic pain and a two or three day history of increasing bladder impairment and perianal and peroneal sensory loss. A follow up letter dated
7 August 2012[16] noted ongoing bladder, bowel and sexual function issues.
[15] Page 96 and 220 of the joint bundle.
[16] Page 100 of the joint bundle.
Dr Christie wrote to QBE on 21 August 2012.[17] On the topic of causation of the claimant’s condition he said:
“The cause of disc prolapse is generally an underlying degenerative problem involving the disc. I see from your letter and also from the subsequent history provided by Mr Dell that he was doing some squats in the gym at work in late March and experienced some back pain at that time. Apparently he also experienced some pain in his back while cycling home from work. I gather that those symptoms subsided reasonably well but then recurred in mid June and escalated over that time requiring his hospital admission and subsequent surgery. There is really no medical way of determining which activities contribute to disc degeneration and subsequent disc prolapse. It is possible that the exercises he was doing in the gym may have contributed to the subsequent disc prolapse. I think it is fairly unlikely that the bike riding would have contributed significantly to his condition.”
[17] Page 104 of the joint bundle.
Dr Barnett referred the claimant to Dr Gale and the spinal unit of Newcastle Hospital on
19 July 2012[18] for treatment of the cauda equina and the claimant’s limited bowel and bladder function.
[18] Page 97 and 216 of the joint bundle.
There is a letter from Dr Gale of the Rehabilitation Medicine Unit at Newcastle dated
27 August 2012.[19] Dr Gale has a history from the claimant of ongoing problems with his bladder, bowels and sexual function as well as back pain. He documents the claimant’s current state as follows:
(a) intermittent self-catheterisation with some awareness of a full bladder;
(b) opening of his bowels five times a day with small amounts;
(c) ability to obtain an erection but without sensation in the penis and no ejaculation noting Viagra was prescribed, and
(d) ongoing back soreness.
[19] Page 106 of the joint bundle.
Advice was given about activity, bowel management, bladder management and additional medication for his sexual function.
Dr Doyle is the claimant’s treating urologist and saw the claimant in early 2012 for revision of his vasectomy. He saw the claimant on 20 August 2012 and reported to Dr Barnett[20] about the claimant’s sexual and bladder dysfunction. On 15 July 2013 he saw the claimant again and reported to Dr Barnett[21] the bladder symptoms appear to have settled but the claimant’s sexual functioning was the main issue.
[20] Page 102 of the joint bundle.
[21] Page 113 of the joint bundle.
Dr Kaur of the Royal North Shore rehabilitation unit wrote to Dr Barnett on
19 September 2012 concerning the claimant’s neurological impairments to his bowel, bladder and sexual functioning.[22]
[22] Page 108 of the joint bundle.
A letter from Dr Barnett dated 5 June 2014[23] concerning the claimant’s medications suggests the claimant was taking Panadol and or Nurofen with Endone prescribed for strong pain on an as needs basis.
[23] Page 117 of the joint bundle.
On 30 March 2015 the claimant attended hospital with priapism following an injection of Caverject the night before.[24] On 8 December 2015 the claimant attended upon Dr Doyle who said[25] the claimant was “not doing too badly”. The bladder symptoms continued, and the claimant was managing this. Sexual dysfunction continued “his erections are good enough to have intercourse but not as good as what they were previously”. He planned to review the claimant in two years. There was no mention of bowel issues in this report.
[24] Page 119 of the joint bundle.
[25] Page 123 of the joint bundle.
Treating medical records and reports
The claimant was transported from the accident scene to hospital by ambulance[26] complaining of lower back and hip pain rated as 6 out of 10 and with minor abrasions to the left knee, ankle and lower limb. The ambulance record has a history of the claimant being struct from behind at about 40kmph.
[26] The ambulance report is at page 124, 262, 575 and 3,074 of the joint bundle.
The John Hunter Hospital notes[27] record the claimant attending complaining of hip pain, lower back pain and left knee abrasions.
[27] Page 130 of the joint bundle.
Dr Barnett’s clinical notes record[28] on 16 June 2017 the accident and injuries sustained (fractured sacrum and some cuts and bruises). The note also reads “REPORTS – no change in background bowel or bladder functions or general motor functions since this new injury. Reports only sacral pain and some bruises and some grazes and is clear on these …”. The claimant was having difficulty getting comfortable when sitting and the claimant wanted to restart Pristiq. He was getting no flashbacks or nightmares.
[28] Page 3,080 of the joint bundle.
On examination there was good range of motion in the neck and shoulders and no gross sensory loss to testing. He said, “for moment no intervention unless escalating or failing to resolve.”
On 26 June 2017 Dr Barnett noted the claimant needed to see Dr Doyle for review of his neurogenic bladder, documented a reliable bowel habit and prescribed medication for the claimant’s sexual function. The fractured sacrum was said to be improving but “Mr Dell remains with lumbar back pain”.
Dr Barnett noted the claimant was continuing to work and be active but, “from time to time
Mr Dell does develop a worsening / flare up lumbar area back pain” and he thought the claimant would benefit from remedial massage.
In a separate record on 26 June 2017, Dr Barnett records pins and needles in the right arm but a good range of motion in the neck and shoulder. There was no sensory loss and
Dr Barnett suggested there was no need for intervention at this stage.
Dr Barnett next sees the claimant on 18 January 2018[29] and his notes document a “simple increase in lumbar sacral soreness”, bowel and bladder symptoms have escalated “as the sore back altered the ability to use pelvic muscles” and the claimant was working but leaving early. There was no radiating pain into the legs and some central low sacral discomfort.
[29] The notes are out of order and somewhat difficult to understand.
Dr Barnett says, “given the back is improving give it more time.” The claimant apparently told Dr Barnett he was thinking of making a CTP claim as the sacral pain felt more related to that accident.
The claimant attended upon Dr Barnett on 16 April 2018 seeking a massage therapy plan. He was complaining of worsening pain and was struggling. He had no leg radiation and the pain had worsened over the Easter long weekend when the claimant did a little more running and physical activity than usual. Dr Barnett documents “Patient feels that the MVA and CTP claim has resulted in this worsening and the pain is a little different to the prior old pain (but not much in it).” The claimant was going to Fiji and needed pain relief for the flight.
Dr Christie, neurosurgeon wrote a letter to Dr Barnett on 9 May 2018.[30] He said the claimant was walking well there was no weakness and no new sensory impairment. He had seen the MRI and did not think there was anything new. There was residual disc bulging at L5/S1 causing no compression. He noted the degenerative changes involving the two discs present on 2012 imaging.
[30] Page 144 and 3,728 of the joint bundle.
On 14 May 2018 the claimant attended Dr Barnett and that his pain “spontaneously settled a day before the MRI scan”. And he had “NO PAIN TODAY”. He reported his back pain had settled to his pre-injury level and he was returning to normal duties.
On 12 July 2018 Dr Barnett referred the claimant to Dr Schwarzer for pain management.[31]
[31] Page 78 of the joint bundle.
Dr Barnett completed a certificate of fitness dated 26 July 2018[32] diagnosing a fractured S3 and “increase in pain focal area in low spine with some mild deterioration in bowel and bladder function”.
[32] Page 44 of the joint bundle.
He also notes a substantial increase in pain in the left sacral area and the claimant was referred to Dr Christie, neurosurgeon, Dr Schwartzer for pain management, physiotherapy, CT scan and continued medication including Endone if necessary.
A further certificate of fitness was completed by Dr Barnett dated 27 August 2018[33] and the doctor reports a conversation he had with the claimant’s workers compensation insurer and says, “this flare up and complications are related to the motor vehicle accident.”
[33] Page 448 of the joint bundle.
Dr Hollo, occupational physician and pain specialist reported to Dr Barnett and EML on
31 July 2018[34] noting the development of symptoms after the June 2017 accident, improvement in November 2017 and then a deterioration in January 2018. She identified a possible L5 left sided neural compromise. Dr Hollo reported again on 17 August 2018[35] after injections into his L5/S1 region. Mr Dell reported some relief at the lumbosacral junction but not the sacral pain. In a third letter dated 24 August 2018,[36] Dr Hollo had injected the left sacroiliac joint which gave some relief to his pain and the claimant could bend forward and was walking better.
[34] Page 2,755 and 3,430 of the joint bundle.
[35] Page 2,761 of the joint bundle.
[36] Page 2,766 of the joint bundle.
On 28 August 2018[37] Dr Hollo wrote a lengthy letter to GIO updating the claimant’s current state and advising Mr Dell was in considerable pain and required an urgent MRI and possible hospital admission. Dr Hollo notes that “currently no one knows which insurer is taking on this liability”.
[37] Page 2,767 of the joint bundle.
Dr Barnett wrote to the case manager of the workers compensation claim on
28 August 2018.[38] Apparently there had been a case conference to consider the apportionment of responsibility between EML and GIO. Dr Barnett thought that which of the two events was causing the claimant’s current presentation “is splitting of hairs”. He noted the claimant’s “very substantial first injury” and that it could “have chosen this time to be more unstable and problematic” but he appears to say there is a correlation between the claimant’s difficulties at work and increasing symptoms and the current car accident.
[38] Page 3,729 of the joint bundle.
On 29 August 2018 the claimant was admitted to John Hunter Hospital due to an increase in his lower back, bowel and bladder symptoms and following an MRI scan.[39]
[39] Page 153 of the joint bundle.
There is a handwritten operation report dated 30 August 2018[40] confirming the L5/S1 laminectomy and discectomy. The dictated operation report[41] from Dr Ferch says that a “wide laminectomy was undertaken” and “a large, sequestrated disc fragment was removed to decompress the nerve roots”.
[40] A522 of AD2.
[41] Page 2,774 of the joint bundle.
Dr Ferch, neurosurgeon wrote to Dr Barnett on 18 October 2018[42] after the post-surgery review. He noted some improvement in bladder function and ongoing low back pain aggravated by sitting. He gave him some stretching exercises and assured Mr Dell he was making good progress. He did not arrange for any further review.
[42] Page 156 and 2,779 of the joint bundle.
Dr Doyle wrote to Dr Millar on 5 August 2019[43] concerning the claimant’s sexual functioning and he appears to relate the 2017 accident with the disc prolapse and surgery.
[43] Page 158 and 2,793 of the joint bundle.
On 10 August 2022 Dr Barnett referred the claimant to the Northern Pain Centre for opinion and management and consideration of the introduction of cannabinoids.[44] Records from Hunter pain specialists suggest cannabis oil was “giving him effective pain relief, improved sleep and is not causing any unwanted [gastrointestinal] side effects” and suggested he continue this medication long term.[45]
[44] Page 161 of the joint bundle.
[45] The letter from Dr Suiter to Dr Barnett dated 5 February 2024 is found at page 3,031 of the joint bundle.
The claimant attended Marketown Health in Newcastle West[46] and saw Dr North there on
22 August 2023 for erectile dysfunction, back pain, fatigue and depression. On
16 October 2023 the claimant reported pain down the back of both legs with occasional cramping in the calves.
[46] Page 2,730 of the joint bundle.
Dr Doyle next saw the claimant on 16 August 2023 and he wrote to Dr North at Marketown Health[47] saying that the claimant was much the same as previously and further advise was given in respect of the claimant’s sexual functioning.
[47] Page 3,027 of the joint bundle.
Radiology
A CT scan was undertaken of the lower back and an MRI on 23 June 2012[48] showing a large disc herniation at L5/S1, small disc bulge and annular tear at L4/5 which appeared acute and traumatic causing effacement of the central canal and impingement of the S2 nerve roots.
[48] The CT scan is at page 88 of the joint bundle. The MRI is at page 240 of the joint bundle.
The CT lumbar scan undertaken at hospital was done on 2 June 2017[49] and showed:
(a) a minimally displaced S3 fracture which “does not appear to be causing any neural compression or impingement”;
(b) a moderate broad based disc bulge at L4/5, and
(c) disc bulge with osteophyte complex and sclerosis at L5/S1 into the intervertebral foramina (right more than left) causing narrowing and touching the nerve roots.
[49] Page 209 and 234 of the joint bundle.
On 19 April 2018 the claimant had an MRI[50] of his lumbar spine due to:
“worsening bladder function with lower back pain increasing focal. No radiation past cauda equina syndrome. MVA in 2017. Increased pain from presumed S3 fracture.”
[50] Page 143 of the joint bundle.
The report notes:
(a) there is evidence of an old healed mid sacral fracture, and
(b) central and right posterolateral disc herniation at L5/S1 impinging the descending nerve roots.
The claimant had a CT scan of his lumbar spine on 12 July 2018[51] which showed L4/5 herniated disc extending into the spinal cord but not impinging the exiting nerve roots and at L5 there were degenerative changes with osteophytes probably impinging the exiting nerve roots.
[51] Page 145 of the joint bundle.
On 29 August 2018, at the request of Dr Hollo, the claimant had an MRI of his lower back with a clinical history provided of “previous cauda equina surgically treated 2012 with discectomy. Recent worsening, similar history, signs and symptoms”.
This scan revealed disc protrusion, extruded disc fragment and “severe, absolute L5/S1 central canal stenosis”.
Medico-legal reports 2012 injury
Dr Ghobrial, orthopaedic and spinal surgeon provided a report to the claimant’s lawyers dated 6 November 2013.[52]
[52] Page 182 of the joint bundle.
He noted the claimant’s injury on 30 March 2012 resulted in a “massive disc protrusion” at the L5/S1 level requiring surgery to treat the cauda equina syndrome. While the pain had improved, Mr Dell was left with bladder, bowel and sexual dysfunction. He thought there was unlikely to be much improvement, the injuries were stable, and he assessed the following WPI (pursuant to the legislative framework in the workers compensation scheme):
(a) lumbar DRE category III – 13%;
(b) discectomy – 3%;
(c) urinary incontinence - 10%;
(d) bowel incontinence - 10%, and
(e) sexual dysfunction – 10%.
The total combined WPI was 39%.[53]
[53] Pursuant to the combined values chart, 13% WPI combined with 10% for urinary incontinence = 22%. 22% combined with 10% for bowel incontinence = 30%. 30% combined with 10% for sexual dysfunction = 37% which combined with 3% for the discectomy produces 39%.
Dr Kalnins, orthopaedic surgeon provided a report to QBE dated 17 February 2014.[54] He records that Mr Dell said his back is “pain free except after prolonged sitting and standing” and he had “persisting saddle anaesthesia” with no change in the symptoms for six months. He diagnosed the cauda equina syndrome with permanent urinary and bowel incontinence but no residual radiculopathy in the legs.
[54] Page 186 of the joint bundle.
Dr Kalnins found the claimant qualified for a DRE category III or 10% and considered there were pre-existing degenerative changes in the lumbar spine warranting a 10% deduction (permitted under the workers compensation legislation) resulting in a WPI of 9%.
Dr Taylor, urologist provided a report to QBE dated 17 February 2014.[55] He too has a history of the claimant’s back pain settling but the persistence of his neurological impairments.
[55] Page 193 of the joint bundle.
Dr Taylor considered the claimant satisfied a class 3 impairment of 33% for Mr Dell’s bladder impairment, class 3 impairment of sexual function which attracts a 20% WPI (which was increased by 50% due to the claimant’s age being under 40). Dr Taylor did not assess bowel impairment and the final WPI was 53%.
Dr Truskett reported to QBE on 7 April 2014. The claimant said he had no real control over his bowels and while he had developed a technique to manage his bladder and bowel symptoms he had experiences of incontinence about once a week. He reported partial erections.
Dr Truskett records “lower back pain all the time” and a loss of sensation in the saddle area. The claimant said he had pain radiating down the back of his legs.
Dr Truskett assessed a class two bowel impairment which attracted a 24% WPI. He disagreed with Dr Taylor’s assessment of class three impairment for bladder and sexual function.
The Panel has not been provided with any determinations from the Commission or its predecessor the Workers Compensation Commission to suggest a final “independent” WPI assessment.
Associate Professor Robertson, psychiatrist provided a report to the claimant’s solicitors dated 6 August 2020. He provides a consistent history of the accident and the development of the claimant’s neurological symptoms. He also documents the emergence of a “severe depressive illness” as Mr Dell’s physical symptoms increased.
Associate Professor Robertson diagnosed a chronic post-traumatic stress disorder, major depressive disorder and alcohol use disorder. He assessed a 7% WPI with an additional 2% for the effects of treatment including medication.
Medico-legal reports 2017 injury
Dr Porteous, occupational physician provided a report to the claimant’s solicitors dated
15 March 2021 following an examination on 17 February 2021.[56]
[56] Page 759 of the joint bundle.
Dr Porteous has a consistent history of the accident and records a significant increase in pre-existing lower back pain thereafter. The claimant also complained of neck and shoulder pain. The claimant reported increased neurological and related symptoms and details of these are given.
Dr Porteous has a history of emergency discectomy and laminectomy on 30 August 2018. He has a history of increasing bladder incontinence since the accident, eight trips to the bathroom a day and more frequent bowel motions. Mr Dell’s sexual function had also diminished. The claimant also complained of numbness in the feet since the second accident. The claimant had ceased physiotherapy and was seeing his GP and urologist.
Mr Dell reported to Dr Porteous that his neck pain has gone, and that his chronic lumbar and sacral pain is the same as 2 to 9 out of 10.
Dr Porteous expressed opinions about the claimant’s ability to work and restrictions he should observe.
Dr Porteous did not offer a WPI assessment.
Dr Gan, neurosurgeon examined the claimant at the request of the insurer on 22 May 2020,[57] he has taken a thorough and comprehensive history via video-link and measurements were taken by an exercise physiologist who was with the claimant.
[57] The report is at page 3,706 of the joint bundle.
Dr Gan diagnosed a blunt injury to Mr Dell’s neck causing neck pain, multiple abrasions and bruising, a blunt injury to the lumbar spine causing low back pain and fracture of the S3 vertical cortex. He also diagnosed an “aggravation of previously well controlled cauda equina syndrome”.
He assessed impairment as follows:
(a) cervical spine – DRE category II = 5%;
(b) lumbar spine – DRE category III = 10%;
(c) bladder dysfunction – 24%;
(d) anorectal dysfunction – 42%, and
(e) sexual function – 20%.
The combined total of these was 71%. Dr Gan then calculated the claimant’s pre-existing impairment of 58% which he subtracted for the current total to arrive at a figure of 13%.
Dr Jones, psychiatrist[58] undertook a psychiatric examination on 3 November 2020 and issued a report dated 3 January 2021. He diagnosed no pre-existing psychiatric impairment at the time of the accident and diagnosed a major depressive disorder in partial remission, no ongoing post-traumatic stress disorder and no active alcohol use disorder.
[58] Page 2,991 of AD1.
Dr Seamus Dalton, sports physician provided a report dated 7 January 2021 after examining the claimant on 6 October 2020.[59] He too takes a comprehensive report of the claimant’s 2012 accident, the 2017 accident and the pattern of symptoms between the two and after the most recent accident.
[59] Page 165 of the joint bundle.
At page six of the report, Dr Dalton records that the claimant’s bladder and bowel function has not changed since the 2017 accident in that he has perianal and perineal numbness, no feeling in the penis and sacral region. He reported occasional urinary leakage and more frequent bowel movements.
The claimant reported loss of strength in his calves and hamstrings, spasms and cramps in both legs and paraesthesia down the back of both thighs.
Dr Dalton expressed the view that the aggravation of the claimant’s pre-existing condition in the accident was temporary and would not account for the acute L5/S1 disc extrusion and the need for discectomy surgery. He considered there was no evidence of any additional lumbar spine pathology and no alteration in the bladder, bowel and sexual function.
Dr Dalton did not offer a WPI assessment.
RE-EXAMINATION FINDINGS
Mr Dell attended a clinical assessment by Medical Assessors O’Neill and Couch at Medical Assessor O’Neill’s rooms at the St Vincent’s Clinic in Darlinghurst on 8 March 2024.
Relevant background history
Mr Dell had a good recollection of past events and his medical history.
Mr Dell suffered Guillain-Barre syndrome in 2008. He said he made a complete recovery from all of the symptoms from this condition over a period of three months.
Mr Dell described a work-related back injury whilst riding his bike in 2012. The Panel notes a CT scan of the lumbar spine on 20 June 2012 reported a large central and paracentral disc extrusion at L5/S1 with associated severe spinal canal stenosis and effacement of the thecal sac. An MRI scan of the lumbosacral spine on 23 June 2012 confirmed a large (11 x 15 x 14mm) disc herniation at L5/S1. Mr Dell said he had a laminectomy performed by Dr John Christie (neurosurgeon) on 23 June 2012 in which there was removal of what was described as an extremely large piece of disc material.
Mr Dell told us this operation immediately greatly relieved his pre-operative back and bilateral leg pain. Mr Dell did confirm there were residual cauda equina symptoms and confirmed the description recorded by Dr Christie on 7 August 2012:
“His main ongoing impairment relates to his lower sacral nerve disturbance. He still has significant bladder impairment. He has to self-catheterise. He still has significant perianal and perineal sensory loss. (He has) small volume bowel movements which require a lot of effort. There has been some return of erectile function which he says has been helped a bit by Viagra. As far as his legs are concerned, he has had a good result and his leg pain has resolved. He has good sensory and motor function in the legs and feet. His ankle jerks are present and he can stand up on his toes quite strongly.”
At a GP consultation on 27 November 2012, it was noted Mr Dell was continuing to self-catheterise, “bowel a little loose but reports that has settled. Finds gets erection but quality is declining – essentially due to no sensation”. Mr Dell confirmed this as correct and said he was prone to recurrent urinary tract infections when self-catheterising and ultimately turned to a Valsalva manoeuvre to evacuate his bladder.
On 18 November 2013 Dr Doyle (treating urologist) stated “he currently voids exclusively by Valsalva manoeuvre”. Dr Doyle also noted “he didn’t have a lot of success with Caverject 10mcgs” for sexual function. Subsequent use of a bigger dose of Caverject resulted in priapism and an attendance at hospital, so that Mr Dell said he no longer attempted to use Caverject.
On 8 December 2015 Dr Doyle reported “his recent ultrasound demonstrated almost complete bladder emptying”. This was as a direct consequence of repeated Valsalva manoeuvre to empty the bladder. Dr Doyle noted “he is currently using a small daily dose of Cialis. He is not sure whether it is giving him much benefit to not. His erections are good enough to have intercourse”. While Mr Dell confirmed the history confirming his bladder habits, Mr Dell said that the persisting loss of sensation involving his penis made it impossible for him to feel the sensation of sexual intercourse but he was able to have intercourse.
Mr Dell told us the persisting loss of sensation in the perianal area was such that he was not able to feel the passage of urine or faeces.
Mr Dell said immediately before the bike accident in 2017 he was able to open his bowels twice a day at the time of a Valsalva manoeuvre. He said there were no episodes of faecal incontinence.
Mr Dell said for over a year before the bike accident in 2017 he only had mild back pain. He was able to run, swim and would cycle 20km each way to and from work.
History of the motor accident
At the time of the accident Mr Dell’s first fleeting thought was of why the bicycle was in front of his body. Immediately thereafter he felt his bottom hit the bonnet of a car and he felt extreme pain in his buttocks and lower back. He remembers rolling down onto the road after impact.
The ambulance report stated “he complains of 6/10 lower back/hip pain. Minor abrasions to left knee, ankle and lower limbs”.
A CT scan of the sacrum at John Hunter Hospital reported “a displaced fracture ventral cortex of the S3 sacral component with associated swelling of the presacral soft tissue”.
Mr Dell said he went back to work within a week of the accident and gradually returned to his usual recreational activities but with pain and modifications as a result.
When asked, Mr Dell identified two types of back pain in the immediate aftermath of the accident:
(a) he described localised pain and tenderness in the region of the fractured sacrum which disappeared completely within about three months after the accident, and
(b) pain in the low back which initially was cyclical so that it would be mild for about three weeks and then more severe, as he returned to work and increased activity. Over time he said the frequency and intensity of this worse low back pain increased, and it came to be associated with pain at the back of both thighs.
On 18 January 2018 Dr Barnett (GP) stated:
“Last week terrible pain. No leg radiation. Can't bend to put on shoes. Bowel and bladder symptoms have escalated as the sore back altered the ability to use pelvic muscles.”
On 16 April 2018 Dr Barnett noted increasing pain:
“Some worsening bowel and bladder control – more likely to have accidents, particularly leaking of urine.”
Mr Dell confirmed that as a result of the worsening in pain and symptoms in early 2018 he was referred to Dr Christie.
An MRI of the lumbosacral spine was undertaken on 19 April 2018 which said:
“There is central and right posterolateral disc herniation causing moderate central canal stenosis and mild to moderate stenosis in the right lateral recess. There appears to be impingement of descending nerve roots and an impression on the thecal sac. The central canal stenosis, however, does not appear critical with CSF[60] seen in the thecal sac around the nerve roots. There is evidence of an old healed mid sacral fracture.”
[60] Cerebrospinal fluid.
At review on 9 May 2018 Dr Christie stated:
“He did notice some increase in his back pain following (the cycling accident). It did seem to be settling down somewhat and then in January became much more severe. The pain was predominantly confined to the central lumbar region. It was very difficult for him to get around because of the pain but fortunately about a month ago it settled down quite significantly and he is pretty much back to his normal self now. On examination he was walking very well, and I couldn’t detect any weakness in his legs. There didn’t appear to be any new sensory impairment. He has had a recent MRI. I don’t think there is anything new. I don’t think there is any need to consider further surgical intervention.”
When this history was put to Mr Dell, he said he could remember clearly that when he saw
Dr Christie he was in a good part of the low back pain cycle which has been described above.
Mr Dell said that his low back pain cycle continued but he developed increasing and worsening pain requiring referral to a pain management specialist, Dr Hollo. He recalled he obtained no benefit from a facet joint injection. Mr Dell recalled that when a second injection was attempted on 29 August 2018 his pain was so severe on the table that he was sent for an urgent MRI scan. This scan revealed disc protrusion, extruded disc fragment and severe absolute L5/S1 central canal stenosis. Mr Dell said he was sent straight from that study to the Emergency Department of John Hunter Hospital. The Panel notes the report found “there was a posterior L5/S1 disc protrusion with a superimposed contiguous extrusion measuring 20 x 10 x 17mm resulting in severe, absolute L5/S1 canal stenosis”. Although the scan was not directly compared to previous radiology, it is clear to the Medical Assessors there was a severe disc extrusion at L5/S1 with virtually complete radiological obliteration of the cauda equina at that level.
Mr Dell was then admitted under Dr Ferch, neurosurgeon. The discharge summary stated he presented with “increased lower back pain and increasing difficulties with urination and opening bowel. More exercise than usual last weekend since which pain has been radically worse”.
A revision L5/S1 discectomy was undertaken by Dr Ferch on 30 August 2018.
As with his 2012 low back surgery, Mr Dell said this operation dramatically improved his back pain so that – in terms of pain – he “felt great the next day”.
Current symptoms
Mr Dell said he had intermittent daily central low back pain. For this he would take Mobic on one or two occasions per week.
He said once or twice per day he could experience a spontaneous, “hot flush like a cramp” down the back of both thighs and this could last for up to 30 minutes. He does not recall this type of thigh pain before the 2017 accident. It was more likely to occur when he was lying down and could wake him from sleep. On three nights per week (prior to his working days) he would use cannabis oil to help with this pain.
Mr Dell said in the aftermath of the bike accident and the 2018 operation his sexual function had “gone entirely”. He could no longer get an erection. There was no response with trials of Cialis or Viagra. He had been given a vacuum device but had not used it. He had been advised against an implant. He is concerned about this and the state of his intimate marital relationship.
Mr Dell did not think there had been any change in his bladder function in the aftermath of the bike accident and the 2018 surgery. He said he would still pass urine by performing a Valsalva on 10 occasions per day. He said he would only have incontinence of urine if he had forgotten to go to the toilet during a night out where he might have a few beers, and this would only be approximately once a week.
Mr Dell said his bowel control was worse after the bike accident and the 2018 surgery. He said he would now produce some faecal matter with each Valsalva manoeuvre and there would be spontaneous loss of bowel control whenever he went swimming – though not with any other form of exercise. He is embarrassed by this in particular the bowel incontinence and it affects what he does and where he goes as he needs to be close to a toilet.
As before, there was no awareness of the passage of urine or faeces and nor was there any feeling in the penis or in the central area around the anus.
He had noticed numbness confined to the right heel in the aftermath of the bike accident and the 2018 surgery, but this was a very localised numbness and did not involve any particular dermatomal distribution.
He was working three days per week as an accountant.
Clinical examination
Cervical spine
There was no continuing complaint of neck pain made by Mr Dell since the accident.
His cervical spine movements were full and painless with no muscle guarding, spasm or asymmetry of movement present. He made no complaint of radiating pain.
Lumbar spine
Mr Dell’s gait was unremarkable.
Romberg's test was negative (the claimant was able to stand on both feet with his eyes closed with no impairment of balance).
Mr Dell was able to stand symmetrically on the balls of both feet, but this produced calf cramping. He was able to dorsiflex both feet from the floor, possibly marginally less on the left.
In terms of the five signs of radiculopathy:
(a) there was tapering of the musculature below the knees and Mr Dell said he had lost muscle bulk in the calves in the aftermath of the cycling accident and the 2018 surgery. There were prominent fasciculations (muscle contractions or twitches) in both calves. There was no wasting of the Extensor Digitorum Brevis muscles (EDB) innervated by L5;
(b) lower limb power was normal on bed testing;
(c) all deep tendon reflexes were symmetrical and normal including retained ankle jerks. The plantar responses were flexor;
(d) there was no sensory impairment to pinprick in the L5 or S1 dermatomes, and
(e) there were no sciatic nerve root tension signs.
Testing of perineal sensation was not felt to be necessary given that there were clear symptoms of loss of perineal (penis and perianal) sensation which had been present before the cycling accident and the 2018 surgery and which, on Mr Dell’s history had not altered in the aftermath of those events.
Consistency
Mr Dell was genuine in presentation and there were no inconsistencies. He gave his history in a straightforward history and confirmed the history as set out in the medical records and reports referred to by the Medical Assessors.
The Medical Assessors considered the claimant presented as a generally stoic individual who did not exaggerate or embellish his symptoms or his situation.
CONSIDERATION OF CAUSATION OF THE CLAIMANT’S BACK INJURY
The issue - causation
There is no issue that the claimant injured his cervical spine, fractured his sacrum and injured his lower back in the accident. However, it is the nature and extent of the lower back injury that is clearly in issue.
The claimant acknowledges in his submissions that he had a pre-existing cauda equina condition causing impairments of his bladder, bowel and sexual functioning. However, the claimant says that these impairments have worsened since his 2017 bicycle accident and that this worsening was caused by the accident.
The insurer’s final submissions do not appear to dispute that the claimant’s neurological impairments relating to his pre-existing cauda equina syndrome have worsened. However, the insurer argues that this worsening, the need for the laminectomy in August 2018 and the claimant’s current presentation is due to either the natural progression of the original 2012 lumbar spine injury or the spontaneous rupture of the previously injured disc. The insurer says this is because the first reports of worsening pain and deteriorating neurological symptoms occurred in January 2018, six months after the accident and that it was not until 19 April 2018 (10 months after the accident) that he reported a link to the car accident and August 2018, 14 months after the accident when the symptoms worsened to such an extent that surgery became necessary.
The test of causation
Section 58(1)(d) requires the Panel to determine the degree of Mr Dell’s impairment as a result of the injury caused by the accident. This requires the Panel to determine:
(a) what was the injury caused by the accident? and
(b) what is the impairment resulting from that injury?
The test of causation of injury that must be applied in any assessment of impairment is set out in the Guidelines as follows:
“[1.6] Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows:
‘Causation means that a physical, chemical or biologic 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 judgement.
[1.7] There 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.”
Could the accident have caused or contributed to the worsening of the claimant’s cauda equina?
The consistent history of the accident is that the claimant was riding his pushbike when he was knocked off it, he hit the bonnet of a car and then fell to the road. The claim form suggests the claimant was riding at 20kmph when he was hit from behind. The ambulance report has a history that the impact occurred at 40kmph. The claimant told Medical Assessors O’Neill and Couch that he remembers hitting the bonnet of a car, rolling onto and down the road after impact. He recalls extreme pain.
The Panel notes the initial lumbar spine CT scan showed a displaced fracture of the S3. It is the clinical judgment of the medical members of the Panel that the mechanism of accident (hit from behind, thrown up onto the bonnet and falling down onto the road) could have caused an additional spinal injury and to the cauda equina injury or contributed to the worsening of the claimant’s cauda equina syndrome. The significance of the forces involved in the crash include the presence of a displaced sacral fracture.
It is the Medical Assessors’ clinical judgment that the forces involved in the accident and the three impacts (the car from behind, the bonnet of the car and the fall to the road) could have caused an injury to the lumbar spine, the discs, surrounding tissues and the cauda equina.
Did the accident cause or contribute to the worsening of the claimant’s cauda equina?
Cauda equina syndrome is a neurological disorder caused by pressure placed on the cauda equina which is a collection of nerves at the base of a patient’s spine. These nerves govern sensation and function in the area of the lower limbs, bladder, bowels and sexual organs.
When the nerves are compressed their ability to control the functions of the limbs, bladder, bowels and sexual organs can be affected and symptoms of weakness, numbness and paralysis will occur.
Because cauda equina symptoms affect several bodily functions and systems, some or all of them are likely to be investigated before a final diagnosis of cauda equina syndrome is made and treatment for the syndrome initiated.
The primary treatment for cauda equina syndrome is to remove the cause of the pressure on the cauda equina nerves. In the case of Mr Dell his 2012 operation was successful in removing a large fragment of disc, and his symptoms improved but were not completely eliminated as damage had been done by the compression of the nerves before the surgery occurred.
The insurer argues that the claimant’s current presentation is due to the original injury and cauda equina syndrome and that it has naturally or spontaneously progressed. The medical members of the Panel do not accept this argument. Once the source of the compression is identified and removed (in this case the 2012 surgery), the syndrome recovers (to a point). It is the clinical experience of the medical members of the Panel that a cauda equina syndrome does not deteriorate spontaneously or naturally progress (like a degenerative arthritic condition might).
The claimant had a vulnerable spine and nervous system before this accident. He had a 2012 injury, the development of cauda equina and a disc which had already herniated, and the extruding material removed surgically. The annulus fibrosis of the L5/S1 disc was already torn, it was vulnerable to further tearing and further extrusion of additional material.
The insurer argues that the claimant’s cauda equina syndrome did not immediately worsen and that the lapse of six months between accident and the emergence of worsening symptoms effectively breaks the chain between injury and the claimant’s current condition.
The medical members of the Panel do not accept this argument. When the history provided by the claimant is considered in conjunction with the medical records there is a medically coherent and plausible connection between the accident on 2 June 2017 and the development of the altered and worse symptoms in early 2018:
(a) the immediate onset of extreme pain at the accident site;
(b) contemporaneous complaints of lower back pain which continued and are recorded in the GP notes;
(c) the claimant’s history given to the Medical Assessors that he continued to have symptoms;
(d) the return to work and gradual return to activity;
(e) the cyclical nature of the claimant’s pain and symptoms which he considered was more like his previous pain and which he self-treated and for which he sought no medical treatment. The Medical Assessors note it is medically plausible that the trauma sustained in the bicycle accident on 2 June 2017 caused symptoms which worsened over time and there can be fluctuations of greater and lesser degrees of pain over that period;
(f) the gradual worsening of the claimant’s worst pain and increase in frequency of symptoms in the cycle of his pain, and
(g)
the absence of any immediate identifiable trigger before January 2018, or
April 2018. The trigger for the surgery was the injection into the claimant’s L5/S1 disc area and the sudden and severe onset of pain as a result.
The Panel is not troubled by the gap of seven months in the medical records. The Medical Assessors note that the claimant had a pre-existing problem that he had been managing for five years and it is not unreasonable that he would have continued to manage this on his own until the pain escalated to such a level that he could not manage it and he sought medical advice.
The Panel is of the view that the 2017 cycling accident caused or materially contributed to the further extrusion of disc material, the recurrence of low back pain which was initially cyclical but became steadily progressive and resulted in the need for a second laminectomy at L5/S1 on 30 August 2018. Surgery was effective in relieving the severe pre-operative back pain.
Worsening disc degenerative disease at L5/S1 as a consequence of the cycling accident and requirement for a second operation has resulted in an aggravation or worsening of pre-existing cauda equina symptoms.
The aggravation has not ceased, and the claimant’s symptoms continue at a level that the Panel is satisfied is at a greater degree than it was immediately before the 2 June 2017 accident.
The medical members of the Panel in particular are, on the basis of their clinical experience satisfied that not only did the 2 June 2017 accident result in a sacral fracture but the trauma involved caused aggravation of the pre-existing degenerative changes at L5/S1 with the further disc injury and the worsening of pre-existing cauda equina symptoms and that, had the accident not happened there would have been no worsening of the pre-accident cauda equina syndrome.
IMPAIRMENT ASSESSMENT
What do the Guidelines provide in terms of spinal impairment?
Assessment of the spine required consideration of Chapter 3 of AMA4 Guides. Only the diagnostic related estimate (DRE) method of assessment is allowed (cl 1.111 of the Guidelines) and there are significant differences between the DRE categories in the Guides and the Guidelines.
While the AMA4 Guides refer to the cervicothoracic, thoracolumbar and lumbosacral spine, the Guidelines (cl 1.131) divide the spine into three regions:
(a) cervical;
(b) thoracic, and
(c) lumbar.
In Mr Dell’s claim, he only alleges injury to the cervical and the lumbar regions.
There are five diagnostic related categories provided for in the Guidelines (there are eight in the AMA4 Guides) and a number of indicia provided to assist an examiner or assessor determining which of the categories is the correct category (see Table 7 in the Guidelines).
The first category is DRE category I which is selected if there are symptoms in a particular spinal region which may include pain.
A classification of DRE category II on the basis of a nerve or nerve root injury requires there to be:
(a) pain with guarding; or
(b) non-uniform range of motion – dysmetria, or
(c) non-verifiable radicular complaints defined in table 8 as:
(i)symptoms (shooting pain, burning sensation, tingling), and
(ii)which follow the distribution of a specific nerve root but no objective clinical findings such as loss or diminished sensation, loss or diminished power or loss or diminished reflexes.
A DRE category III is allowed for nerve or nerve root injuries where there is pain and two or more of the five signs of radiculopathy provided for in cl 1.138:
(a) loss or asymmetry of reflexes (see Table 8 in the Guidelines);
(b) positive sciatic nerve root tension signs (see Table 8);
(c) muscle atrophy and/or decreased limb circumference (see Table);
(d) muscle weakness that is anatomically localised to an appropriate spinal nerve root distribution, and
(e) reproducible sensory loss that is anatomically localised to an appropriate spinal nerve root distribution.
The Panel notes that cl 1.113 of the Guidelines provides that:
“The assessment of spinal impairment is made at the time the injured person is examined. If surgery has been performed, then the effect of the surgery … must be taken into consideration when assessing impairment.”
There is a similar clause at 1.25 which requires “past treatment (for example operations)” to be considered when assessing impairment.
In Mr Dell’s case, there are other DRE categories provided for in Table 7 of the Guidelines which may be relevant including:
(a) previous spine operation without radiculopathy, and
(b) previous spine operation with radiculopathy.
What is Mr Dell’s cervical spine impairment?
The claim form, the application to the Commission and the submissions to the Panel allege an injury to the cervical spine. Mr Dell told Medical Assessors O’Neill and Couch that he injured his neck in the accident. The insurer does not appear to dispute that the claimant injured his neck in the accident.
The Panel is satisfied on the basis of the claimant’s history and the contemporaneous hospital and GP documentation that Mr Dell did sustain an injury to his neck in the accident of 2 June 2017.
The medical members of the Panel are satisfied that the nature of the cervical spine injury was a soft tissue injury, and on the claimant’s history to the Medical Assessors on
8 March 2024, that the claimant has fully recovered from it.
Clause 1.21 of the Guidelines provide that an injured person’s impairment is assessed as they present on the day. In the absence of any symptoms of pain, the claimant does not fall into any of the DRE categories.
This finding of no impairment does not mean the claimant did not sustain an injury to his neck it simply means that in accordance with the legislative framework, there is no assessable impairment percentage that can be allowed today for that injury.
What is Mr Dell’s impairment due to his sacral fracture?
The insurer does not dispute that the claimant sustained a fracture to his sacrum in the accident.
Clause 1.154 of the Guidelines provides that section 3.4 of Chapter 3 of the AMA4 Guides (page 131) must be used. This provides for assessment of disorder in the pelvic region as follows:
(a) healed fracture without displacement or residual sign(s) - 0%;
(b) healed fracture with displacement and without residual sign(s) involving the sacrum – 5%, and
(c) healed facture with displacement, deformity and residual signs involving the sacrum, into the sacroiliac joint – 10%.
The Panel is satisfied on the basis of the claimant’s history and the contemporaneous hospital records that the claimant sustained a fracture of the sacrum at the S3 level in the accident. The Panel finds on the basis of the CT scan undertaken on 2 June 2017 this was a minimally displaced fracture.
The Panel notes that in a scan of the claimant’s lumbar spine dated 19 April 2018, there was a record of an old healed mid-sacral fracture which appears to be a reference to the S3 fracture sustained in the accident.
There is no comment in the report of this scan as to whether the fracture has healed with displacement or not. Mr Dell did not attend with the imaging.[61] It is the view of the medical members of the Panel that if there was some displacement, no matter how minor, it would have been noted by the radiologist particularly in the light of the clinical history recorded in the report, “increased pain from presumed S3 fracture”.
[61] Although it is possible it was in the material lodged on 26 March 2024 which the Panel has been unable to access and which we have refused to allow into evidence.
In the first preliminary conference report dated 30 May 2023 the original Panel pointed out to the parties that an S3 fracture could attract a 0%, 5% or 10%. In the directions of
24 January 2024, the Panel requested final submissions as to the assessment of WPI for amongst other things, the fractured sacrum.
The claimant provided no submissions as to how the fractured sacrum should be assessed and whether the claimant’s injury warranted a finding of 0%, 5% or 10% WPI.
As clause 1.21 requires an assessment of the impairment “as it is at the time of the assessment”. Mr Dell told Medical Assessors O’Neill and Couch that the pain around his fractured sacrum resolved three months after the accident.
The Panel notes that the claimant has provided no additional medical or radiological evidence to suggest there is currently any displacement of the S3 fracture.
On the basis that the fracture has healed and there are no residual signs including pain, the Panel is of the view that the claimant’s sacral fracture should be assessed as 0% WPI. As there is no evidence of current displacement of the fracture, the Panel is of the view that the claimant cannot be assessed as having a WPI of 5% for this injury.
A finding of no impairment does not mean the claimant did not sustain an injury to his sacrum it simply means that in accordance with the legislative framework, there is no greater impairment allowed for that injury.
What is the impairment for Mr Dell’s lower back injury?
Current impairment
There is no doubt the cycling accident resulted in recurrence of low back pain which was initially cyclical but became steadily progressive and resulted in the need for a second laminectomy at L5/S1 on 30 August 2018. Surgery was effective in relieving the severe pre-operative back pain.
The claimant has pain, therefore he attracts at least a DRE category I (0%) impairment.
Mr Dell has non-verifiable radicular complaints in terms of a burning sensation in the back of both of his thighs which follows a L5/S1 distribution. While Mr Dell had no guarding or dysmetria he does qualify for at least a DRE category II due to the radicular complaints.
In terms of a DRE category based on the presence of radiculopathy, the Panel notes that on examination:
(a) reflexes - all were present and equal including the hamstring jerk which Medical Assessor Dixon remarked was absent at the time of his examination;
(b) there were no positive nerve root tensions signs in the lumbar spine;
(c) muscle atrophy and / or decreased limb circumference – there was no wasting of the EDB muscles (innervated by the L5 nerve) and the loss of musculature and bulk in both calves after the accident does not appear to be due to the effects of any neurological injury but appears due to the claimant’s general lack of fitness and loss of condition since the time of the accident;
(d) muscle weakness – there was none, muscle power was normal, and
(e) reproducible sensory loss – there was none in the L5 or S1 dermatomes. The numbness in the claimant’s right heel did not confirm to either of the relevant dermatomes.
Based on the above findings the claimant does not have radiculopathy.
The Panel also notes in respect of Mr Dell:
(a) there is no vertebral body compression of greater than 50%;
(b) Mr Dell does not have spondylolisthesis;
(c) there is no lumbar vertebral body fracture (noting the sacral fracture must be assessed in accordance with a pelvic injury), and
(d) there is no stenosis, facet arthrosis or disease.
What Mr Dell has had however is lumbar spinal surgery (being a laminectomy and discectomy at the L5/S1 level on 30 August 2018). Table 70 of AMA4 and table 7 of the Guides provides a DRE for “previous spine operation without radiculopathy” and permits a range of categories II – IV.
The Guides and Guidelines do not include a definition of “previous spine operation” but in the context of assessing Mr Dell’s current impairment, this would appear to be a reference to the “past treatment” or “past surgery” the claimant has had.
The Guides and Guidelines also do not provide any guidance or examples which might assist in determining which of the three categories (II, III or IV) should be chosen. In clause 1.163 a Medical Assessor is told to nominate the appropriate impairment percentage “based on the complete clinical circumstances revealed during the examination and provide reasons”. While this clause is found in the neurological section of the Guidelines (and not the spinal section), this clause does provide some guidance to the Medical Assessors on how to approach whether Dr Dell should be placed in category II, III or IV. It is a matter for the Medical Assessor’s discretion after considering the claimant’s complete clinical circumstances.
It is the clinical judgment of the medical members of the Panel that the claimant’s lumbar spine musculoskeletal disorder should be currently assessed as DRE category IV. Mr Dell has, as a result of the 2 June 2017 accident, had a worsening of his lumbar spine symptoms, aggravation of his back pain and worsening of his cauda equina syndrome, he has had second surgery to remove a large piece of herniated disc and he has continued symptoms caused by a worsened cauda equina syndrome.
The Panel notes that a DRE category IV attracts a WPI of 20% and the Panel is satisfied that this is an accurate and appropriate assessment which reflects the complete clinical circumstances of Mr Dell.
Pre-existing impairment
The insurer has submitted that cl 1.31 of the Guidelines requires the Panel to assess any pre-existing impairment and subtract it from the current impairment but only if there is evidence of a pre-existing symptomatic impairment.
It is the Panel’s view that the medical records and reports indicate the presence of a symptomatic impairment at the time of the accident. Both Dr Ghobrial in November 2013 for the claimant and Dr Kalnins in February 2014 for the workers compensation insurer assessed the claimant as DRE category III (10%). Mr Dell also confirmed the presence of previous back symptoms. The history he gave did not clearly indicate the presence of radiculopathy in the weeks and months before the June 2017 accident.
In the context of an assessment his pre-accident impairment, Mr Dell had “previous spine surgery” in the form of a laminectomy on 23 June 2012 which as we have explained above attracts a range of DRE categories II – IV. The Panel notes that the 2012 surgery improved the claimant’s back pain, left him with no radiculopathy but did not completely resolve the claimant’s cauda equina syndrome.
The Panel is satisfied that immediately before the 2017 accident the claimant would have been assessed as having a DRE category III impairment in respect of his lumbar spine pursuant to table 70 of AMA4 and table 7 of the Guidelines on the basis of “previous spine operation without radiculopathy”. A DRE category III impairment attracts a 10% WPI.
Impairment caused by the accident
When the pre-existing impairment (10%) is deducted from the claimant’s current impairment (20%), the Panel is satisfied that the claimant has a 10% WPI in respect of the lumbar spine injury he sustained in the accident.
CONCLUSION
Medical Assessor Dixon’s certificate
It is the Panel’s finding that in respect of the injuries assessed by Medical Assessor Dixon the claimant’s degree of permanent impairment is:
Area of the body injured
Current impairment
Pre-existing symptomatic impairment
Degree of impairment caused by the accident
Cervical spine
0%
N/A
0%
Lumbar spine
DRE IV 20%
DRE III 10%
10%
Fractured sacrum
0%
N/A
0%
Any impairment Mr Dell may have in respect of his bladder, bowel or sexual functioning will be considered in the Review proceedings concerning the assessments of Medical Assessors Korbel and Garvey.
The Panel has come to the same conclusion as Medical Assessor Dixon, that is that Mr Dell does not have a WPI of greater than 10%. Although it is for different reasons the Panel considers that Medical Assessor Dixon’s certificate should be confirmed.
Combined certificate
Section 63(5) requires the Panel to issue a new combined certificate. Clause 1.45 of the Guidelines provides that separate impairment percentages are not simply added but must be “combined” in accordance with the combined values chart on pages 322 – 324 of the AMA4.
The total WPI is calculated by the Panel at 28% as follows:
(a) the claimant’s current bowel impairment assessed with a WPI of 15%;
(b) combined with the musculoskeletal impairment in these Review proceedings of 10% equals 24%;
(c) combined with the sexual dysfunction impairment assessed at 5% equals 28%, and noting
(d) there is a 0% impairment in relation to the claimant’s bladder function.
A combined certificate will be issued certifying that the claimant has a greater than 10% WPI.
- AGLC
- AAI Limited t/as GIO v Dell (No 1) [2024] NSWPICMP 216
- Case
- [2024] NSWPICMP 216
- Decision Date
CaseChat Overview and Summary
The Panel found that the mechanism of the accident could have caused or contributed to the worsening of the claimant’s cauda equina syndrome, and that it did cause or contribute to the worsening of the syndrome. The Panel accepted the claimant’s explanation for the absence of symptoms in the records. The fractured sacrum was assessed at 0%, as there was no subsequent evidence suggesting the fracture remained displaced. The neck injury had resolved and attracted no impairment. The lower back injury was assessed on the basis that there was a previous surgery with no radiculopathy, resulting in a pre-existing impairment of DRE II. The WPI was assessed at 10%, and a combined certification of greater than 10% was issued. The Panel confirmed Medical Assessor Dixon’s assessment of 10% WPI.
The court found in favour of the claimant and dismissed the insurer's appeal. The court confirmed the WPI assessment of 10% and ordered the insurer to pay the costs of the appeal.
Orders
Orders of the court
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Background
Background to the litigation
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Evidence
Evidence Before The Court
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Decision
Reasons for decision
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Ratio Decidendi
Legal Principle Established
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