1. The parties agree the issue remaining in dispute is whether the C5-C7 anterior decompression and fusion surgery proposed by Dr Singh is reasonably necessary medical treatment as a result of injury on 7 May 2019 pursuant to s 60 of the Workers Compensation Act 1987 (1987 Act).

1. The parties appeared for conciliation conference and arbitration hearing on 1 October 2025 in Sydney. Ms Alfaro was present with her husband Mr Alfaro. Mr Jarryd Malouf of counsel appeared for the applicant instructed by Ms Nathalie Ghneim, legal practitioner. Mr Greg Young of counsel appeared for the respondent instructed by Ms Imogen Mahoney, legal practitioner, and Mr Lean was also present.
2. During conciliation the respondent objected to the admission of the applicant's Application to Lodge Additional Documents dated 26 September 2025 with the further report of Dr Singh, treating spine surgeon.
3. The respondent submitted it would be disadvantaged if the report were to be admitted and there would be a lack of procedural fairness. The applicant did not seek leave at the preliminary conference on 6 August 2025 to put on additional evidence. The applicant has pleaded two level surgery at C5 to C7 and the amount sought is $20,698.50. Dr Singh's quote of 8 April 2020 is for single level surgery at C6 to C7 in the amount of $20,698.50. The respondent's independent expert Dr Gambhir provides a report on 30 December 2024 regarding only C6 to C7 surgery and he has not had the opportunity to consider two level fusion surgery. If Dr Singh's latest report had been available earlier the respondent could have requested Dr Gambhir's opinion on two level surgery.
4. The applicant submitted the request for surgery had been made many years previously.

Dr Singh is the applicant's treating specialist and is not an independent medical expert.

Dr Singh's request for two level surgery appears to have been made in March or April this year although that request is not in evidence. The respondent did not request a comment on two level surgery at that time. Two level surgery is pleaded in the ARD and the question was not asked or raised by the respondent earlier. There is an estimate of fees for surgery with the ARD dated 1 November 2022 for C5-C6 and C6-C7 anterior cervical decompression and fusion in the amount of $13,071. The applicant conceded costs of two level fusion were not with the ARD and undertook to provide an updated quote. 5. Following consideration of counsel's submissions I admitted the applicant's Application to Lodge Additional Documents dated 26 September 2025 pursuant to r 67C(4) of the Personal Injury Commission Rules 2021 (Rules). I was satisfied the introduction of the document was necessary to facilitate the just, quick and cost-effective resolution of the real issue in the proceedings which is whether the surgery proposed by Dr Singh is reasonably necessary as a result of the applicant's injury. 6. The application was made no later than three working days before the conciliation/arbitration in accordance with r 67C(1) of the Rules as the respondent conceded, and is the one occasion only on which the applicant has lodged additional documents. There is no requirement in the Rules that a party seek leave at a preliminary conference to put on additional evidence. 7. The initial request for surgery was made in 2020. A request for two level fusion surgery appears to have made at least earlier this year and is pleaded in the ARD filed on

7 July 2025. As Dr Gambhir does not support single level fusion surgery at this time it would seem unlikely he would change his view and support two level fusion surgery. The prejudice to the applicant of a delay in her proceedings, noting this is a request for surgery, was not in my view outweighed by potential prejudice or lack of procedural fairness to the respondent in the circumstances. 8. I am satisfied the parties to the dispute understand the nature of the application and the legal implications of any assertion made in the information supplied. I have used my best endeavours in attempting to bring the parties to the dispute to a settlement acceptable to all of them. I am satisfied the parties have had sufficient opportunity to explore settlement and that they have been unable to reach an agreed resolution of the dispute.

1. The following documents were in evidence before the Commission and considered in making this determination:

(a) ARD and attached documents;

(b) Reply and attached documents, and

(c) applicant's Application to Lodge Additional Documents dated 26 September 2025 and attached document (ALAD).

1. No application was made to adduce oral evidence.

1. The applicant relies on her statement signed on 8 October 2020 and three supplementary statements.
2. In her statement of 8 October 2020 the applicant describes commencing employment with the respondent as a General Services Officer part time in June 2022 working around

35 hours a week, and when the Cook was unavailable she assumed their role and carried out their duties on increased pay. She generally worked two days a week in the role of Cook and three days as a General Services Officer. 3. On 7 May 2019 she was preparing to cook the evening meal when she pressed the power button on the gas/electric deep fryer and suffered an electric shock. She fell backwards to the ground and landed heavily on the concrete floor against her back and right shoulder. 4. The applicant sustained injuries to her right shoulder, neck, lower back, right leg and right heel as well as a psychological injury in the form of post-traumatic stress disorder. 5. Regarding her cervical spine injury, the applicant continued to experience neck pain following the injury. An X-ray was taken on 9 May 2019, physio was recommended, the pain in her neck persisted and then became particularly debilitating. 6. She was referred to Dr Manish Gupta, orthopaedic surgeon, who referred her for an MRI on 12 August 2019. This showed stenosis and disc bulging at multiple levels on her neck. An ultrasound carried out at Nepean Hospital evidenced a bulging disc at the C5/6 level impinging on her nerve. Dr Gupta referred the applicant to Dr Singh in August 2019. 7. Dr Singh proposed physiotherapy for her neck symptoms and an injection, and he referred the applicant to Dr Shawn Watson, neurologist. Dr Watson carried out a nerve conduction study and the applicant understands the results appeared normal. Physiotherapy helped to reduce pain in her right shoulder and neck. 8. In November 2019 Dr Singh explained the applicant would likely require fusion and decompression surgery to her neck and referred her to Western Sydney Pain Clinic for assessment. Dr Singh then recommended a guided injection to the C6/7 level and reiterated if the pain continued she would require neck surgery. The applicant had the guided injection in January 2020. She noticed some initial pain relief however it only lasted a few days. The pain became more severe. 9. On 25 March 2020 Dr Singh formally recommended the applicant undergo anterior cervical decompression and fusion at C6/7 as she had exhausted all conservative treatment options. She wished to go ahead as she did not feel she could continue to manage the severe pain in her neck any longer. She cannot bear the thought of living with the pain in her neck indefinitely. 10. The pain in her neck and the right side of her body hinders her ability to complete activities of daily living. 11. In her supplementary statement of 4 March 2022 the applicant says she continued to consult her general practitioner (GP) Dr Kulanayagam and when he ceased working at that practice she began consulting Dr Guillerma De Leon. Relevantly she says her neck and lower back had deteriorated causing chronic pain and disabilities. 12. She returned to work on light duties in 2021 but she had persistent restrictions in her right shoulder, neck and upper back. Her pain woke her up at night. She attended physiotherapy which slightly helped to reduce her symptoms. She had treatment for a frozen right shoulder, took pain medications and anti-depressants. She continued to experience restricted range of movement and pain including in her neck. She struggles with daily living activities and self-care. 13. In her supplementary statement of 14 March 2024 the applicant addresses the treatment dispute regarding the fusion surgery proposed by Dr Singh. The applicant confirms she had no back or neck pain before the injury in 2019. 14. Dr Singh's view is the fusion at C6/7 is necessary in attempting to improve her condition and quality of life, she has exhausted many alternate treatment methods with little relief from her ongoing pain and discomfort, the treatment is appropriate and widely accepted by practising spine surgeons, and the alternative would be permanent functional incapacitation. 15. Dr Khong is also supportive of the proposed treatment. His view is while there are alternate options, given her ongoing pain those methods are unlikely to bring her long-term pain relief. A C6/7 fusion could be an appropriate treatment in his view. 16. The applicant feels she has exhausted all other treatment options and has no choice but to have the surgery. Her constant pain and discomfort has continued to exacerbate her psychological condition and she constantly feels hopeless and miserable. She is in immense pain and she is prepared to try anything to reduce her symptoms and restore some degree of quality of life. 17. In her supplementary statement of 26 June 2025 the applicant disagrees with Dr Gambhir's opinion and she believes Dr Singh's report should be considered as more reliable and accurate. Dr Khong continues to support the proposed treatment as being reasonably necessary. In his last report Dr Khong noted alternate treatment options of a C6 and C7 perineural injection and in his most recent report he noted the applicant failed to see any improvements through non-operative management. 18. The applicant continues to be in immense pain and she is prepared to do anything to reduce her symptoms and restore some degree of quality of life, especially by having the surgery recommended by Dr Singh and supported by Dr Khong. She just wants to get this surgery done so she can alleviate the pain she is suffering from in an attempt to recover and move on with her life.

1. Dr Khong reports on 19 July 2023 the applicant has non-verifiable radicular complaints related to her cervical and lumbar spine. She likely has musculoligamentous strain of the cervical spine and also degenerative disc disease at C5/6 and C6/7 with foraminal stenosis at both levels. She likely experienced an exacerbation of these previously asymptomatic degenerative changes in her cervical spine. The effects of the injury have not ceased.
2. The need for a C6/7 anterior cervical decompression and fusion was directly caused by the applicant's workplace injury. Dr Khong's opinion is she may benefit from having sequential right C5/6 and C6/7 perineural injections. If both injections significantly help with her pain then fusion at one or both of these levels would be appropriate in his view.
3. Alternatives including analgesia, physiotherapy and steroid injections are unlikely to bring her long-term pain relief given the applicant has had pain for over four years. The cost of a single level fusion is approximately $10,000.
4. If there is evidence that the applicant's pain is related to C6 +/- C7 neural compression, a fusion would be accepted as appropriate and likely to be effective. Surgery on her cervical spine may reduce some of her right sided neck and arm symptoms.
5. On 28 May 2025 Dr Khong reports the applicant returns with persistent midline and right sided paraspinal neck pain radiating down the right arm. Surgery is likely to result in some improvement in her right sided neck and arm pain.
6. Dr Khong recommends a C5/6 and C6/7 anterior cervical discectomy and fusion.
7. The applicant recalls two weeks of improvement in her symptoms after the right C7 perineural injection and her MRI demonstrates right sided C5/6 foraminal stenosis and likely right C6/7 foraminal stenosis. It is now six years since her injury and she has failed non-operative management. She does not want further steroid injections.
8. At this stage a C5/6 and C6/7 anterior cervical discectomy and fusion is reasonably necessary in Dr Khong's opinion. She will not improve without surgery.

Dr Mohammed Assem, independent rehabilitation specialist

1. On 19 August 2020 Dr Assem reports relevantly that the applicant sustained a soft tissue injury to the cervical spine and continued to have neck pain and stiffness.
2. There was loss of sensation in the C7 dermatomal distribution although there was no concordant evidence on radiological imaging of nerve root impingement.
3. Her underlying degenerative cervical disease pathology has been rendered symptomatic. There was moderate cervical canal stenosis at C5-6 consistent with the symptoms reported.
4. Dr Assem's opinion is the applicant would benefit from ongoing physiotherapy to reduce neck pain and she has declined to proceed with the proposed anterior cervical decompression and fusion. The surgery may be necessary if there is unrelenting pain or a progressive neurological deficit. Dr Assem assesses 6% whole person impairment of the cervical spine.
5. In his supplementary report of 9 September 2021 Dr Assem comments on Dr Keller's opinion about the injury and its effects.

1. On 25 May 2020 Dr Chow takes a history including of ongoing neck and arm pain which has not changed over time. Her ongoing neck pain radiates to the right arm and is worse than the shoulder and back pain.
2. Dr Chow diagnoses post-traumatic stress disorder and adjustment disorder as a result of the work injuries. He assesses 19% whole person impairment.
3. Dr Chow's report of 23 December 2021 includes that the applicant has deteriorated further and is now suffering from major depressive disorder.

1. On 20 September 2020 Dr Singh provides an unequivocal diagnosis of an injury to the cervical spine clearly seen on imaging, confirmed by diagnostic injection and related to the workplace incident. She has a disc injury and bulging at C6/7.
2. Without treatment she is likely to have ongoing symptoms, she has structural pathology in the cervical spine and has failed treatment by non-operative means. The surgical option of decompression and fusion is reasonably necessary. A surgical fee estimate was provided at gazetted rates.
3. Dr Singh reports on 4 August 2023 the applicant has ongoing pain down her arm and has evidence of disc bulging at C5-6 and C6-7 giving rise to foraminal stenosis on the right.
4. There was temporary relief during the anaesthetic phase by an injection in her cervical spine but her pain has now returned and he recommends she consider surgery as a more durable solution.
5. Asked whether he considers the fusion at C6-7 to be reasonably necessary medical treatment, Dr Singh notes she has had disabling symptoms for several months which have not responded to medication, and injections have only given her short-term relief. The MRI scan of the cervical spine reveals a structural pathology with compression of the neurological elements and therefore surgery is reasonably necessary and appropriate. The alternative is to accept pain management and permanent functional incapacitation. The cost is commensurate with the gazetted rates.
6. The treatment is effective as it will decompress the neurological elements in the cervical spine and stabilise the injured motion segments from C5 to C7 in Dr Singh's opinion. This is an appropriate method of treatment and accepted by practising spine surgeons.
7. On 5 March 2025 Dr Singh reports to Dr De Leon that he recommended anterior cervical decompression and fusion from C5 to C7 for nerve compression resulting in pain and weakness in the right arm two and a half years ago.
8. A CT scan of the cervical spine reports similar findings as before with severe stenosis in the cervical spine on the right side at C5/6 and bilateral stenosis at C6/7. The applicant has not been getting better without surgical treatment.
9. The surgery should be decompression in the cervical spine and this should be along with a stabilisation of range of motion segments from C5-C7. Dr Singh was to send a request to the insurer.
10. Dr Singh provides a review on 15 April 2025 in follow-up with the applicant. There had been no response to the request made for surgery in early March, and it was not approved two and a half years ago. The symptoms have become worse.
11. Dr Singh provides a further report on 12 September 2025. He still believes the proposed C6-C7 anterior cervical decompression surgery is reasonably necessary.
12. The applicant still has neck and arm pain with pins and needles going to the right hand. She has weakness of the right triceps and diminished sensation in the right C6 and C7 dermatomes. A recent CT scan again shows severe stenosis at C5/6 and bilateral stenosis at C6/7. The aim of surgery is to decompress the nerves thereby improving her neck and arm pain, also allowing her to have some recovery of motor function.
13. She has exhausted all recommended conservative treatment options available having trialled bed rest, physiotherapy, medication, hot packs, ultrasound, massage and previous spinal injections.

Dr Sathiyapal Kulanayagam, treating general practitioner

1. Dr Kulanayagam's report of 20 September 2020 with respect to the applicant's cervical spine includes that on 8 May 2019 she had neck pain after the electrocution and the pain continued. She had seen the orthopaedic surgeon and had a CT scan of the cervical spine.
2. Dr Kulanayagam believed the applicant needed extensive physiotherapy, gym-based exercises and hydrotherapy. She must be referred to an orthopaedic surgeon after at least 10 sessions of physiotherapy and gym-based exercises to consider any surgical options.

1. Ms Moodley reports on 25 July 2019 the applicant initially presented with upper thoracic pain, cervical pain and altered sensation into the arm. The cervical pain continues to persist.

1. The applicant was discharged from Nepean Hospital on 15 August 2019 having presented with right sided headache and paraesthesia/numbness of upper limbs on a background of recent occupational injury (electrocution and fall onto back) with resulting C5/C6 foraminal stenosis without nerve root compression or canal stenosis.

1. Radiology reports concerning the applicant's cervical spine include a CT scan on

1 September 2021 that concludes right foraminal stenosis potentially compressing the right C6 nerve root and multilevel low-grade facet joint arthropathy throughout the cervical spine. 2. The CT scan of 26 October 2021 concludes moderate right-sided foraminal stenosis of C5/6 level with potential impingement of right C6 nerve root. 3. The CT scan of 31 December 2024 comments on multi-level cervical spondylosis similar to previous reports, with the changes appearing most advanced at C5/6 where there is severe right foraminal stenosis with potential impingement of the exiting right C6 nerve root. At C6/7 there is bilateral foraminal stenosis, mild-moderate on the right and mild on the left.

1. The clinical records of NSW Spine Specialists, The Healthy Body Company, Rouse Hill Medical Imaging, Joslyn Stanley, psychologist, and Ropes Crossing Medical Centre are with the ARD.
2. The Rouse Hill Medical Imaging MRI cervical spine report of 1 September 2022 concludes minor disc degenerative changes at C6/7 with impingement of bilateral C7 exiting nerves and at C5/6, with possible irritation of the right C6 exiting nerve and no high-grade canal stenosis.

Workers Compensation Commission Certificate of Determination

1. The applicant's earlier proceedings were discontinued by way of a Certificate of Determination - Consent Orders on 9 February 2021, and it was noted the respondent was to pay the applicant voluntary weekly compensation from 12 April 2020 to date and continuing.

1. The respondent's Notification of Injury is dated 7 May 2019.

1. The incident on 7 May 2019 is described in the Accident/Incident Form with the location of injury shown as arm and hand with pins and needles.

1. The respondent relies on s 78 notices issued on 26 May 2021, 5 December 2022 and

29 January 2025, and internal review outcome notices of 1 February 2022, 22 September 2023 and 19 June 2025.

1. Radiology reports with the reply include an X-ray cervical spine of 30 December 2014 that finds satisfactory cervical alignment, normal outline of the neural exit foramina and no significant degenerative change.
2. The CT scan report of 25 May 2015 includes the impression of mild C5/6-disc disease with minimal broad based disc bulge and minimal right foraminal narrowing at that level, with no other significant abnormality.
3. Dr Khaga refers the applicant to Dr Al-Khawaja on 2 June 2015 for opinion and management including for cervical disc disease and left neck pain with referred arm pain, with disc prolapse at C5/6 and radicular pain at C5/6 distribution.
4. Dr Jahan refers the applicant to Greater West Physiotherapy & Health Centre on

21 August 2015 for opinion and management of cervical C5-6 degenerative disease. 5. Dr Khaga carried out a team care arrangement review on 28 December 2015 with one of the goals met being to improve function including of cervical disc disease. 6. Dr Khaga's GP Management Plans between 28 September 2015 and 22 February 2017 include as one of the goals met being to improve function including of cervical disc disease. 7. Dr Kulanayagam refers the applicant to Nepean Hospital on 21 October 2018 for opinion and management of chest discomfort and burning sensation for one week, weakness in the right arm, tingling as well as numbness and also neck pain. Examination is unremarkable and she needs further assessment. 8. Dr Phillip Brown, independent psychiatrist, provides a report to the respondent on

17 December 2019 regarding the psychological aspects of her claim, not relevant to these proceedings. 9. The applicant's current symptoms included very severe pain at the back of her neck and down the right leg. She also has pain at the right side of her neck and the pain has been there since the accident and has got worse and worse. The right sided-neck pain radiates down the right arm at the ulnar side and goes to the middle finger. 10. Dr Brown reports on 4 May 2021 regarding the applicant's claim for permanent impairment. 11. The comments and opinions in his report include that the applicant is for the major part malingering her physical symptoms and their cause all remained salient. 12. The applicant reports her main physical problem is the pain in her right neck. Dr Brown opines that the applicant should have whatever surgical treatment is necessary to alleviate her organic pain, as for as long as she has organic pain needing such surgical alleviation then she is likely to present with some form of adjustment disorder. 13. Dr Brown concludes the applicant has no ongoing psychological condition due to the work-related injury on 7 May 2019 and this has been the situation for a prolonged time.

Dr Andrew Keller, independent occupational physician

1. On 17 February 2020 Dr Keller reports the applicant's presenting complaint is constant right sided neck pain radiating to the right shoulder. Dr Keller's opinion is there are no objective findings that any injuries presented that day that can be attributed to the subject work incident.
2. In Dr Keller's opinion her current physical presentation is clearly inconsistent and exaggerated. There is no objective evidence of ongoing physical injuries that require further treatment.
3. On 20 January 2021 Dr Keller reports the applicant's presenting complaint is constant neck pain that radiates to the right shoulder, worst at night and better with activity. On examination Dr Keller relevantly found inconsistent restriction of motion in the cervical spine.
4. Dr Keller is unaware of any research that links electric shocks with cervical disc injuries and he is not convinced there is any objective evidence of injury to the cervical spine, lumbar spine or shoulders.
5. Referring to the MRI of the cervical spine on 12 August 2019, Dr Keller's opinion is the findings are consistent with age-appropriate degenerative changes, of which there is similar evidence on her lumbar spine scan. There is no evidence the applicant suffered any acute cervical spine injury as a result of the work incident.
6. There was inconsistent restriction of motion in the neck, shoulder, back and inconsistent weakness in the applicant's ankles. Dr Keller's opinion is the physical findings are inconsistent and not explained by the reported work injury.
7. Dr Keller does not agree with Dr Assem's impairment assessment of the cervical spine on careful consideration of the history of the incident, the investigation findings and the injuries that can be assessed.
8. Dr Keller provides a supplementary report on 6 May 2021.
9. Asked to expand on his opinion as to why the shock itself did not injure the worker, Dr Keller says there was a brief exposure to a 240V shock. No local burns or cardiac symptoms were reported or investigated, and the only other expected condition would be muscular pain from sudden contraction which would be temporary, lasting for a few days only, and from which there would be a full recovery with or without treatment.
10. Asked whether the fall itself injured the applicant or aggravated any asymptomatic or symptomatic degenerative condition, Dr Keller says it is possible to suffer muscle, ligament and bone injuries from falls. He notes the applicant appears to have reported neck pain going to the left arm and investigations were requested the day following the incident. It is possible a fall could temporarily exacerbate degenerative changes in the spine with resolution of symptoms expected within a few weeks only.
11. Reviewing the clinical records of Ropes Crossing including the applicant's complaints prior to 7 May 2019 relevantly regarding her neck, Dr Keller comments there is a long history of neck complaints radiating to her arms that predates her reported injury and required prior investigations and specialist referral. In his opinion the subject incident has not caused her any lasting restrictions or treatment needs, and her symptoms can be attributed to her prior degenerative conditions.
12. Dr Keller confirms the applicant's presentation was inconsistent and no objective findings of lasting physical injuries from the reported incident were observed.

Dr Shanu Gambhir, independent neurosurgeon and spine surgeon

1. On 30 December 2024 Dr Gambhir reports the applicant's current symptoms appear to be a combination of neck pain and some right arm radiculopathy and right shoulder pathology.
2. On Dr Gambhir's review of the MRI cervical spine the nerve compression in 2022 was not severe.
3. The applicant has had these symptoms for around two years now and in Dr Gambhir's opinion spinal surgery is unlikely to provide her with any significant improvement and he would not recommend surgery at this stage.
4. The applicant could be managed conservatively with pain relief on a needs-basis. She may continue with physiotherapy if it provides relief and she could perform home-based exercises. If her symptoms do get worse in future she will need review with a new MRI of the cervical spine and right shoulder pathology.
5. Dr Gambhir confirms the applicant had pre-existing degenerative changes in her cervical spine which were essentially asymptomatic before the injury. Since the incident at work where she was thrown heavily to the ground from the electrocution he believes that had rendered the degenerative changes symptomatic, and her symptoms continue.
6. The applicant was consistent in her clinical presentation and Dr Gambhir did not find any abnormal illness behaviour or attempts to exaggerate her symptomatology. He diagnoses neck pain and right arm radicular radiculopathy.
7. Regarding the C6/7 anterior cervical decompression and fusion proposed by Dr Singh,

Dr Gambhir's opinion is that her symptoms have been stable for the last two years and her last MRI in 2022 did not show severe nerve compression, so that overall he does not believe the surgery will provide her with significant symptoms relief. If her symptoms were to worsen, correlated well with repeat MRI, then surgery could be considered. 8. Dr Gambhir agrees with Dr Khong that the applicant should be managed conservatively at this stage.

1. On 5 April 2011 the applicant is referred to Nepean Hospital for physiotherapy by Dr Dang, presenting with right shoulder pain, paraesthesia in fingers, right sided face and neck pain starting the day before, and right arm pain starting in the hand and radiating upward.
2. A cervical spine X-ray of 29 March 2011 concludes there is minimal degeneration of the mid facet joints bilaterally.

1. The applicant made oral submissions which have been recorded and form part of the Commission's record. These are summarised below.
2. Injury is no longer in dispute as Dr Gambhir makes clear.
3. The applicant's statement evidence sets out the treatment she has undergone including consultations with a GP, physiotherapy, home based exercises, consultation with the psychologist and a pain management specialist and injections to her neck which provided initial relief that lasted a few days, and hydrotherapy.
4. The applicant submits there have been considerable attempts to resource conservative measures and nothing else is offered by Dr Gambhir. The applicant wants to have the surgery because she has been told that it will help her. She has constant immense pain and discomfort. She has exhausted all other options and she constantly feels hopeless and miserable. She has had the risks explained to her and having considered that she maintains she requires the fusion surgery. That remains the case in 2025.
5. Dr Singh provides an initial quote for one level fusion and then a separate quote for both levels C5-C6 and C6-C7 on 1 November 2022 which appears to have left off anaesthetist fees.
6. Dr Singh diagnoses a disc injury and bulging at C6/7, disagreeing with the opinion of

Dr Keller at that time that there is no injury. Dr Singh says there clearly is on the imaging and confirmed by a diagnostic injection related to the workplace incident. 7. Dr Gambhir upon whom the respondent now relies, says it is not severe enough to warrant surgery. 8. Dr Singh identifies nerve compression on the scans and he says her pain and function will improve with the surgery. Without surgery she is likely to have permanent functional restriction and ongoing pain. 9. Dr Singh refers to anterior decompression and fusion at C5/6 in this report. 10. In Dr Singh's 2023 report he identifies C5 to C7 that need to be stabilised and says the applicant has not responded to conservative measures. MRIs have confirmed it, surgery is reasonably necessary and appropriate and the alternative is to accept pain management and permanent functional incapacitation. The cost is within gazetted rates and treatment is effective as it will decompress in neurological elements in the cervical spine and stabilise the injured motion segments C5 to C7. It is an appropriate method of treatment accepted by practising spine surgeons. 11. That is echoed in his next report almost two years later. The updated CT scan has similar findings with severe stenosis. The applicant has not been getting better without surgical treatment. Dr Singh maintains his view that the surgery is reasonably necessary. 12. In his report of September 2025 Dr Singh who has been reviewing the applicant for five years says her symptoms have become worse. 13. While he is specifically asked about C6 to C7 he recommends surgery at C5 to C7, which he has previously recommended. 14. Dr Singh has provided five years' worth of assessment and treatment recommendations that have been constantly ignored. The result is the applicant has got worse and he has had absolutely no reason to change his opinion about the surgery being reasonably necessary. 15. Dr Singh refers to the CT scans of the cervical spine of September 2021 and December 2024. 16. Dr Kulanayagam confirms in 2020 there has been a great deal of conservative treatment but she must be referred to an orthopaedic surgeon to keep an eye on things and consider any surgical options. 17. Dr Khong identifies the applicant's significant symptoms. In relation to the issue to be determined he says the prognosis is poor without surgery and with surgery the applicant is likely to have some improvement in her right sided neck and arm pain. 18. It has been six years since her injury and she complains of persistent neck and right sided arm pain. Conservative treatment has failed. Dr Khong recommends a C5/6 and C6/7 anterior cervical discectomy and fusion, which is of course what Dr Singh has also recommended. She will not improve without surgery. 19. Dr Singh, the applicant's treating orthopaedic and spine surgeon who has been seeing the applicant for five years, and Dr Khong are saying the same thing. There is no other alternative recommended. They agree the surgery is reasonably necessary and the applicant says she wants to have it done. 20. Looking at Diab[1] and Rose[2] there is no part that would be of concern as the surgery is appropriate, available and there is no issue foreseen about costs. 21. The applicant does not have to prove there definitely will be an improvement but actual potential effectiveness and Dr Singh and Dr Khong certainly go well beyond that and say that it will. 22. Dr Gambhir does not really take issue with any of the matters in Diab and Rose except for effectiveness. In short Dr Gambhir says the compression is not that severe and so the applicant should not have surgery. He does not say how he comes to that conclusion or why he says it is not too severe. 23. Dr Gambhir says the applicant should stick to conservative measures however they have not been helpful in the past so why would they be now? He does not offer any alternatives. 24. In the context of the applicant's history and the opinions of Dr Khong and Dr Singh the applicant's submission is Dr Gambhir's opinion is unpersuasive on depriving the applicant of the surgery, and on the basis the compression is not severe enough which significantly undermines what the applicant is going through. 25. For that reason the opinions of Dr Singh and Dr Khong should be preferred and the orders sought should be made.

1. The respondent made oral submissions which have been recorded and form part of the Commission's record. These are summarised below.
2. Dr Gambhir's opinion is the basis on which the respondent disputes the need for surgery.
3. The basis of Dr Gambhir's opinion is what we know objectively as well as what he finds on clinical examination.
4. On his clinical examination of the applicant's cervical spine Dr Gambhir notes mild restriction in range of motion due to pain, neurological examination of the upper limbs revealed normal tone bilaterally and power was 5 out of 5 bilaterally and sensation was normal and symmetrically bilaterally.
5. The clinical examination forms part of Dr Gambhir's opinion.
6. The other aspect is Dr Gambhir was provided with a number of materials listed in his report that includes the two 2021 CT scans of the cervical spine and the 2022 MRI and X-ray of the cervical spine which Dr Gambhir refers to specifically and bases his opinion on.
7. The respondent is not raising the issue of injury or whether the injury may well have resolved by now. Dr Gambhir confirms the symptoms continue.
8. Dr Gambhir is asked about C6/7 anterior cervical decompression and fusion so we at least know what his opinion is relating to that. By extension the respondent can say that opinion also relates to the level above because of the logic and the basis of Dr Gambhir's opinion.
9. In relation to his clinical findings Dr Gambhir says on his review of the MRI cervical spine the nerve compression was not severe. The applicant has had symptoms for around two years and in his opinion spinal surgery is unlikely to provide her with any significant improvement and therefore at this stage he would not recommend spinal surgery.
10. If her symptoms do get worse in the future she will need review with a new MRI of the cervical spine and right shoulder pathology.
11. Dr Gambhir does not recommend surgery at this stage and she could be managed conservatively with pain relief on a needs-basis and she could continue with physiotherapy if it provides relief.
12. The applicant says there is not much more the applicant can do in terms of conservative treatment. It is true she has done physiotherapy and she has had pain management but what she has not done is have a repeat MRI.
13. She has had a CT scan and the respondent submits there has not been much change. In fact the CT scans do not expressly say that there is nerve compression. The very thing

Dr Singh wants to release is pressure on the nerves but the scans do not show it. We do not know why there has not been a repeat MRI. 14. Dr Gambhir says based on the radiology we have, in other words what we know objectively, surgery is not warranted. 15. The question is what else can be done conservatively before having the surgery and that is an MRI scan, or something else that can be done through Medicare like a nerve conduction study. That is what Dr Singh suggested back in 2019 and 2020 which we know because the applicant refers to it. 16. The applicant was referred to Dr Watson, a neurologist, who arranged a nerve conduction study. Her statement evidence is that she had a nerve conduction study and to the best of her recollection the results appeared normal. The respondent accepts that since that time the applicant has gotten worse. 17. A nerve conduction study might confirm there is the radiculopathy Dr Singh assumes because there is nothing objective to show it. 18. The respondent's submission is the clinical findings of Dr Singh and Dr Khong have nothing objective to support them. The applicant says she is worse, that is what she said subjectively and there is a focus on C6/7, and now on both levels with C5/6 as well, but again we should look at the CT scans. 19. The September 2021 CT scan shows at C5/6 reduced disc height, disc osteophyte complex resulting in mild to moderate right foraminal stenosis, or narrowing of the canal, which can sometimes put pressure on the nerves. There is no disc protrusion at C6/7 and yet at this stage Dr Singh wants to operate. The conclusion is that the CT scan does show right foraminal stenosis potentially compressing the right C6 nerve root. This is not actual but potential, not probable, not definite but potentially compressing the right C6 nerve root again. At this stage there is nothing at the level below. 20. The October 2021 CT scan shows at C5/6 there is mild posterior disc bulging with moderate right and mild left sided foraminal stenosis. At C6/7 there is mild posterior disc bulging without notable central canal or foraminal stenosis. 21. The conclusion is moderate right sided foraminal stenosis at C5/6 with potential impingement of right C6 nerve root. Again it is potential impingement which is not confirmed. The recommendation is for an MRI study to be performed. 22. An MRI is then performed, referred to by the doctors including Dr Gambhir. 23. There is another CT scan in December 2024 with a clinical history of ongoing neck pain with radiculopathy and it is compared with September 2023 and October 2021 CT scans and describes again potential nerve root impingement at C6 on the right and possibly at C7. 24. The comment is that there is multi-level cervical spondylosis similar to previous reports and the changes appear most advanced at C5/6. There is reference again to potential not actual impingement. There is nothing actually confirmed objectively. 25. Dr Gambhir was not satisfied objectively so it boils down to clinical judgement. 26. The applicant says Dr Singh should be accepted as he has seen the applicant over five years. The respondent's submission is that Dr Singh says the scans say far more than what they actually showed. 27. In August 2023 Dr Singh says the MRI scan of the cervical spine reveals a structural pathology with compression of neurological elements. 28. We do not have an updated MRI scan. The respondent's submission is Dr Singh is almost flying blind in the sense that he does not know what an MRI scan would show now, and we do not even know what a nerve conduction study says, contrary to Dr Singh's own practice of arranging one, so there would be objective evidence of neurological compression. 29. If there was objective evidence Dr Gambhir would perhaps change his mind. At this stage he is saying quite sensibly that it is not the time to have this surgery. 30. Dr Khong suffers the same difficulty. In his first report Dr Khong sees some radiology but he does not refer to what Dr Singh is assuming which is nerve root compression. 31. Dr Khong's clinical examination of the applicant's cervical spine includes it is normal with sagittal and coronal balance. There is nothing really there on clinical examination. 32. Dr Khong's report of May this year offers little assistance. His examination is very similar to his previous examination and there does not seem to be objective clinical signs of nerve compression in the respondent's submission. 33. Little weight should be placed on Dr Khong's report in the respondent's submission. 34. What Dr Singh has not done in terms of further conservative measures is to confirm with objective testing what he assumes, and for that reason you would accept Dr Gambhir's cautious and measured opinion. This can and should be a reasonable alternative at this stage.

1. The applicant submits that there is nerve involvement and that any concerns about that would be immediately alleviated because the respondent's own doctor says there is.
2. While it is interesting to look at the scans we are not doctors and every single doctor in this case says there is compression. Dr Gambhir himself says there is compression and radicular radiculopathy and nothing more needs to be shown.
3. On 5 March 2025 Dr Singh reports on neck pain and radiculopathy and he never says there is no compression and radiculopathy. He has looked at the scans and his opinion should therefore be given more weight.
4. We are not doctors. The respondent submits Dr Singh has assumed some things but the applicant submits that is not a fair submission. He has looked at the MRI and he has not just relied on reports. As a medical doctor he has formed a view there is compression, as has every other doctor, and he says the surgery is reasonably necessary. He has looked at the evidence as has Dr Khong.
5. The respondent has identified one further treatment that could be obtained and that is an MRI. Rose and Diab say if there is something else available it does not mean that is fatal to the claim. Dr Singh already has an MRI from three years ago and he says the surgery is reasonably necessary.
6. The respondent also submits that objective evidence of compression is needed. MRIs do not present objective evidence. They are the best evidence in terms of radiology but they do not prove anything objectively. In any event that would be completely unnecessary as every single doctor says there is nerve involvement.
7. There is nothing that suggests the surgery is not reasonably necessary.

Is the C5-C7 anterior decompression and fusion surgery proposed by Dr Singh reasonably necessary medical treatment as a result of injury on 7 May 2019

1. Section 60 of the 1987 Act provides for the payment by an employer of the cost of any reasonably necessary medical or related expenses received by a worker as the result of an injury in addition to any other compensation payable under the Act.
2. The legal test when determining whether proposed treatment is reasonably necessary as a result of a workplace injury was considered by Roche DP in Diab;[3]

"Reasonably necessary does not mean 'absolutely necessary' (Moorebank at [154]). If something is 'necessary', in the sense of indispensable, it will be 'reasonably necessary'. That is because reasonably necessary is a lesser requirement than 'necessary'. Depending on the circumstances, a range of different treatments may qualify as 'reasonably necessary' and a worker only has to establish that the treatment claimed is one of those treatments. A worker certainly does not have to establish that the treatment is 'reasonable and necessary', which is a significantly more demanding test that many insurers and doctors apply."

1. In Diab Roche DP cites the decision of Burke CCJ in Rose with approval. While the essential question remains whether the treatment is reasonably necessary, the following are useful heads for consideration:

(a) the appropriateness of the particular treatment;

(b) the availability of alternative treatment, and its potential effectiveness;

(c) the cost of the treatment;

(d) the actual or potential effectiveness of the treatment, and

(e) the acceptance by medical experts of the treatment as being appropriate and likely to be effective.[4]

1. Reasonably necessary medical or related treatment as a result of an injury must be assessed on a case by case basis, with the Commission exercising "prudence, sound judgment and good sense".[5]
2. Dr Singh first recommended the applicant consider anterior cervical decompression and fusion at C6/7 in February 2020 and requested approval for the surgery on 8 April 2020.

Dr Singh says in October 2022 that over the last two years her pathology at C5/6 had also worsened and surgery was reasonably necessary. A request for surgery with an estimate of fees for C5/6 and C6/7 surgery was made on 1 November 2022. 3. The respondent submits and I accept the reports of the CT scans of the applicant's cervical spine in 2021 and 2024 refer only to potential impingement of the C6 nerve root. 4. The applicant's symptoms are objectively confirmed however by the 2022 MRI of the cervical spine that concludes "[m]inor disc degenerative changes at C6/C7 with impingement of bilateral C7 exiting nerves and at C5/C6, with possible irritation of the right C6 exiting nerve."[6] 5. Dr Khong initially recommended conservative treatment, however in 2025 he notes persistent pain and recommends the proposed surgery. 6. Dr Singh and Dr Khong are satisfied including on the basis of the 2022 MRI that the proposed surgery is reasonably necessary and I accept their opinion. 7. The respondent refers to Dr Gambhir's clinical examination of the applicant that forms part of his opinion. Dr Gambhir's examination of the applicant revealed mild restriction in range of motion due to pain. Dr Gambhir makes a diagnosis of neck pain and right arm radicular radiculopathy, and the work related aggravation remains causative of her current condition. 8. While Dr Gambhir agrees the applicant has neck pain and right arm radicular radiculopathy, the nerve compression shown in the 2022 MRI is not severe in his opinion and overall the surgery will not provide the applicant with significant symptom relief. 9. In December 2024 Dr Gambhir describes the applicant as having had her current symptoms for around two years, although she reported ongoing symptoms involving her neck since the time of the injury in 2019. 10. I do not accept on a consideration of the evidence that the applicant has only had her current symptoms for around two years at the time of Dr Gambhir's report although they may have worsened in that period. 11. The applicant's statement evidence is that she had difficulty managing severe pain in her neck in 2020. After some initial pain relief from the guided injection in January 2020 the pain became more severe. By 2022 her neck condition had deteriorated causing chronic pain and disabilities. In 2024 the applicant feels she had exhausted all other treatment options and she has no choice but to have the surgery. She is in immense pain. 12. Aside from Dr Keller's opinion, there is no evidence the applicant has been other than consistent in her clinical presentation. I accept the applicant's evidence that she has experienced severe neck pain. 13. Dr Gambhir proposes the applicant could be managed conservatively with pain relief and physiotherapy, and if her symptoms were to worsen a repeat MRI should be undertaken before surgery could be considered. 14. The applicant's evidence is that physiotherapy only slightly helped to reduce her symptoms, she has taken pain medication and her symptoms have worsened. 15. Dr Gambhir agreed with Dr Khong that the applicant should be managed conservatively however Dr Khong subsequently changed his opinion, supporting the recommended surgery. 16. I am not persuaded by Dr Gambhir's opinion that further conservative treatment should be undertaken before the recommended surgery is carried out as conservative treatment over many years has failed to improve the applicant's symptoms. 17. The applicant has had X-rays and CT scans of the cervical spine as well as MRIs in 2019 and 2022. 18. I do not agree with the respondent's submission that a repeat MRI is required as part of conservative treatment before contemplating surgery. I accept the submission made by the applicant that the availability of other treatment is not fatal to determining whether the proposed surgery is reasonably necessary. 19. I prefer Dr Singh's opinion in this case. Dr Singh as the applicant's treating surgeon has examined her over several years and in that time arranged investigations, attempted conservative treatment and he provides a well-reasoned opinion that the proposed surgery is reasonably necessary. Dr Khong supports Dr Singh's recommendation. 20. The applicant submits that of the matters considered in Diab and Rose Dr Gambhir only really takes issue with the question of effectiveness. A review of each of the matters considered in those cases supports a finding that the surgery proposed by Dr Singh is reasonably necessary as a result of the work related injury.

1. In Dr Singh's opinion the proposed treatment is effective as it will decompress the neurological elements in the applicant's cervical spine and stabilise the injured motion segments from C5 to C7, and it is an appropriate method of treatment. This will allow the applicant to have some recovery of motor function.
2. Dr Khong recommends a C5/6 and C6/7 anterior cervical discectomy and fusion as it is likely to result in some improvement in the applicant's right sided neck and arm pain. He notes the improvement in the applicant's symptoms after the right C7 perineural injection.
3. Dr Gambhir's opinion is that as the applicant's symptoms have been stable for the last two years and the MRI in 2022 did not show severe nerve compression, overall he does not believe the surgery will provide the applicant with significant symptoms relief and surgery could be considered if her symptoms were to worsen correlated with a repeat MRI. I am not persuaded by this opinion as discussed above.

Availability of alternative treatment, and its potential effectiveness

1. Dr Kulanayagam suggests in 2020 that after at least 10 sessions of physiotherapy and gym based exercises surgical options ought to be considered. The applicant notes in 2022 she attended physiotherapy which slightly helped to reduce her symptoms, and in 2024 she refers to Dr Singh's view that she has exhausted many alternate treatment methods with little relief from ongoing pain and discomfort.
2. In December 2024 Dr Gambhir agrees with Dr Khong that the applicant should be managed conservatively at this stage, with pain relief on a needs-basis and continuing with physiotherapy if it provides relief and home-based exercises. The applicant's statement evidence suggests physiotherapy has provided little relief and she has tried pain medication.
3. Dr Khong's opinion changed by May 2025. Alternatives including analgesia, physiotherapy and steroid injections are unlikely to bring long term relief given the period over which the applicant has experienced pain. In Dr Khong's opinion the applicant has failed non-operative management.
4. Dr Singh notes the applicant has exhausted all recommended conservative treatment options available having trialled bed rest, physiotherapy, medication, hot packs, ultrasound, massage and spinal injections. Dr Singh says the alternative is to accept pain management and permanent functional incapacitation.

1. Dr Gambhir does not refer to the cost of the proposed surgery. Dr Khong suggests the cost of a single level fusion is approximately $10,000.
2. Dr Singh confusingly provides two fee estimates, the first of $20,698.50 for C6-C7 anterior cervical decompression and fusion plus in-patient rehabilitation following discharge from hospital, and the second for $13,071 for C5-C6, C6-C7 anterior cervical decompression and fusion plus in-patient rehabilitation following discharge from hospital. Dr Singh confirms however the cost is commensurate with the gazetted rates.

Actual or potential effectiveness of the treatment

1. Dr Singh's view is the surgery by decompressing the nerves will improve the applicant's neck and arm pain and allow her to have some recovery of motor function.
2. In Dr Khong's opinion at this stage a C5/6 and C6/7 anterior cervical discectomy and fusion is reasonably necessary. She will not improve without surgery.
3. Dr Gambhir accepts that if the applicant's symptoms were to worsen surgery could be considered, but at this stage overall he does not believe the surgery will provide her with significant symptoms relief.
4. I have not accepted Dr Gambhir's opinion on the severity or duration of the applicant's symptoms as discussed above.

Acceptance by medical experts of the treatment as being appropriate and likely to be effective

1. Dr Assem's opinion in 2020 was that the surgery may be necessary if there was unrelenting pain or progressive neurological deficit. The evidence establishes the applicant has experienced unrelenting pain.
2. Dr Singh comments that the surgery is accepted as appropriate by practising spine surgeons. Dr Khong recommends the surgery.
3. Dr Gambhir says surgery could be considered if the applicant's symptoms were to worsen correlated well with repeat MRI. I am not persuaded the applicant's current symptoms are relatively recent and are not severe.
4. The medical evidence supports that the proposed surgery is accepted as appropriate and likely to be effective, although in Dr Gambhir's opinion further conservative treatment ought to be pursued first which I have not accepted in the circumstances of this case.
5. For the respondent to be liable for the costs of the proposed treatment the applicant must establish the accepted injury materially contributes to the need for that treatment.[7] There is no dispute the accepted injury materially contributes to the need for the proposed treatment.
6. The applicant has discharged her onus to establish on balance the C5-C7 anterior decompression and fusion surgery proposed by Dr Singh is reasonably necessary medical treatment as a result of her injury on 7 May 2019.

1. The C5-C7 anterior decompression and fusion surgery proposed by Dr Singh is reasonably necessary medical treatment as a result of injury on 7 May 2019 pursuant to s 60 of the 1987 Act.
2. There will be an order that the respondent is to pay the costs of the C5-C7 anterior decompression and fusion surgery proposed by Dr Singh and ancillary costs at the appropriate SIRA gazetted rates.

[1] Diab v NRMA Limited [2014] NSWWCCPD 72 (Diab).

[2] Rose v Health Commission (NSW) [1986] NSWCC 2; (1986) 2 NSWCCR 32 (Rose).

[3] [2014] NSWWCCPD 72 at [86].

[7] Murphy v Allity Management Qt Services Pty Ltd [2015] NSWWCCPD 49 (Murphy).