(a) whether the treatment is reasonably necessary treatment as a result of the injuries, and the extent and quantification of the applicant's entitlement to payment of medical and related expenses pursuant to s 60 of the 1987 Act.

1. No application for leave to cross-examine was made and no oral evidence was given.

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

(a) ARD and attached documents;

(b) Reply to ARD and attached documents, and

(c) Application to Lodge Additional Documents filed on behalf of the applicant on

27 October 2025.

1. The applicant provided evidence by way of two written statements.
2. In a statement dated 20 August 2025, the applicant stated:

(a) following an injury in 2005, he then underwent an L5/S1 laminectomy and disc excision and rhizolysis of the S1 nerve root, which led to an improvement in symptoms and him being able to continue working full-time in physical jobs without any until the accepted injury in March 2022;

(b) on 1 March 2022, he sustained the accepted injury when his backside and lower back were jolted as the wheels of a forklift that he was driving fell into an excavated hole which had been left uncovered;

(c) he experienced severe backpain at the time of the accepted injury and subsequently developed worsening back, left leg weakness and left sided foot drop;

(d) he sought medical treatment and underwent multiple procedures for those symptoms which included: total left hip replacement on 25 September 2023; L4/5 and L5/S1 anterior interbody fusions and pedicle screw fixation on

18 January 2024; an L4/5 and L5/S1 anterior lumbar interbody fusion on

27 May 2024; a left L5 nerve root decompression on 25 June 2024;

(e) he continues to experience persistent and worsened left foot drop and worsened numbness in his left foot and toes to the extent that he now has almost no feeling on his left foot and toes;

(f) he is also distressed by ongoing lower back pain, which radiates down into his left leg in a lightning-bolt type manner and he also now also experiences intermittent right leg pain, tingling and numbness;

(g) since developing his left foot drop, he regularly stumbles and trips and he is now heavily reliant on the use of a walker and/or walking stick and is now severely restricted in his ability to go out and to shower and dress, and

(h) he wishes to undergo the treatment as he believes it will provide him with relief and improve his quality of life.

1. In a statement dated 26 September 2025, the applicant stated that:

(a) in the early days after his accepted injury, he tried a splint to assist with his left foot weakness, however he found it to be uncomfortable and unsupportive and his foot still twisted and felt very unstable;

(b) his work boots provided more support than the splint, but he still experiences instability, and

(c) he is now very reliant on a walker and/or walking stick for mobility.

1. The treating medical evidence discloses the following history, which I accept:

(a) between November 2001 and October 2006, Professor Youseff Ghabrial, orthopaedic and spinal surgeon, issued various reports in relation to ongoing back pain with right leg symptoms, and involving his cervical spine and lumbar spine, which the applicant developed since 1992 and that the applicant had an aggravation at work on 21 December 2004. Professor Ghabrial noted that the applicant had right L5/S1 disc prolapse with sequestration. On 21 June 2025, Professor Ghabrial performed L5/S1 laminectomy, and rhizolysis of the S1 nerve roots, which diminished the applicant's problems although the applicant had some residual symptoms in his back and legs, including cramping and pins and needles in his left leg. Professor Ghabrial attributed the applicant's condition and surgery to aggravation at work on 21 December 2024 and assessed 14% total whole person impairment as a result of the injuries sustained on

21 December 2004;

(b) on 7 December 2021, an X-ray of the left foot, was reported to show degenerative changes of multiple joints;

(c) on 8 December 2021, the applicant was treated at Wyong Hospital in relation to left ankle pain and pain in his lower limb and hip;

(d) on 11 April 2022, an X-ray of the left foot, was reported to show mild degeneration of multiple joints;

(e) on 14 April 2023, an X-ray of the hips, knees, left ankle, was reported to show advanced bone-on-bone arthropathy of the left hip with bony remodelling and likely impingement;

(f) on 14 April 2023, a CT scan of the lumbosacral spine was reported to show spinal canal compromise in the lower lumbar spine, with facet arthropathy most severe at L4/5 and foraminal compromise most severe at L5/S1;

(g) on 15 July 2023, Dr Coughlan, treating neurosurgeon, reported that, after having worked in construction for many years involving heavy lifting, the applicant had developed progressively worsening leg pain and back pain, a severe antalgic gait, he could not support himself on his left leg and had a reduction in hip flexion on the left side. Dr Coughlan noted that the applicant had significant degenerative changes in the lumbar spine but noted that the main issue seemed to be his left hip with severely denuded left lift hip joint with bone on bone. Dr Coughlan stated that he thought the applicant may require a decompression in his lumbar spine although the priority was his severe left hip pain which required a hip replacement. Dr Coughlan noted that the applicant would get an MRI of the lumbar spine;

(h) on 20 July 2023, Dr Michael Hunter, orthopaedic surgeon, reported a history that following the accepted work injury, the applicant had gradually progressive left leg pain, functional loss and weakness as a result of severe left hip osteoarthritis and L5/S1 compression in his spine. Dr Hunter reported that on examination the applicant's hip demonstrated no range of movement in flexion, severe irritability and was fixed in a rotated position which made gait difficult and that the applicant walked with a severely antalgic abductor gait. Dr Hunter noted that a radiography of the applicant's left hip showed severe chondral loss, bony loss, deformity present and spur function and that a CT scan of his back showed significant L5/S1 lateral recess problems, which corresponded with the applicant's neurological loss in his lower limbs. Dr Hunter recommended that the applicant undergo hip replacement surgery;

(i) on 21 July 2023, an MRI of the lumbar spine was reported to show mild to moderate central canal stenosis at L4/L5 and degeneration of the bilateral L4/L5 and L5/S1 facet joints, right central disc osteophyte complex at L5/S1 and mild contact with the right S1 nerve root;

(j) on 9 August 2023, an X-ray of the left foot and ankle was reported to show mild osteoarthritic changes and clawing of toes;

(k) on 25 August 2023, Dr Coughlan reported that the applicant had very significant left leg pain and had mild to moderate central canal stenosis at L4/5 and some stenosis at L3/4 with some mild lateral recess stenosis. Dr Coughlan recommended a left L3/4 and L4/5 lateral recess decompression;

(l) on 25 September 2023, an X-ray of the left hip was reported to show a total joint replacement in position with no complication seen;

(m) on 11 November 2023, Dr Coughlan reported that the applicant was doing well after undergoing hip replacement, although he still had left-sided foot drop.

Dr Coughlan recommended that, as a priority, the applicant undergo decompression. Dr Coughlan noted that the applicant already had approval for L4/5 and L3/4, and he also sought approval for decompression of L5/S1.

Dr Coughlan stated that the decompression was to improve the nerve function especially on the left-hand side, and that it was not aimed to improve his axial back pain. Dr Coughlan noted that the applicant had some narrowing at L5/S1 with effacement of the S1 nerve root. Dr Coughlan stated that the applicant may later also require a procedure to put spacers at L5/S1 and L4/5 to address the collapse of the disc and the foraminal stenosis;

(n) on 18 January 2024, Dr Coughlan reported that the applicant underwent L3/4, L4/5, L5/S1 decompression;

(o) on 1 March 2024, a CT scan of the lumbosacral spine was reported to show similar interval appearances to previous scans except for findings of interval left-sided laminectomy and improvement of the spinal stenosis;

(p) on 1 March 2024, Dr Coughlan reported that the applicant had noticed significant reduction of leg pain since his decompression. Dr Coughlan noted that the applicant did still have quite marked foot drop on the left side and he had noted that the leg seemed to be rolling over and had weakness in dorsiflexion.

Dr Coughlan noted that the CT scan demonstrated chronic bilateral foraminal stenosis affecting L5/S1 however the applicant only really had motor deficit on the left side. Dr Coughlan sought an updated CT scan;

(q) on 22 March 2024, Dr Coughlan noted that the applicant was having ongoing issues with long-standing foot drop. Dr Coughlan noted that the applicant previously underwent a decompression, and expressed concern that some of the compression of the nerve was in the foramen, although curiously the applicant was not rolling his foot and falling on the right despite having bilateral foraminal narrowing. Dr Coughlan recommended that the applicant undergo nerve conduction studies to determine whether it was primarily a radicular issue or whether he also had issues related to his common peroneal nerve down stream which could contribute towards his left leg weakness;

(r) on 17 April 2024, Professor Robert Heard, neurologist, reported on nerve conduction studies, and concluded that there is no evidence of focal peroneal nerve lesion at the fibular head although an incomplete left sciatic trunk injury was not excluded. Professor Heard recommended a neurology review;

(s) on 26 April 2024, Dr Coughlan reported that nerve conduction studies showed that the applicant had bilateral L5 issues and no significant common peroneal nerve compression. Dr Coughlan noted that the applicant's gait had deteriorated, he was becoming more incapacitated, his foot drop was quite severe on the left and was becoming a falls risk, and the applicant was also getting significant issues on the right side. Dr Coughlan recommended an L4/5 and L5/S1 anterior interbody fusion with posterior pedicle screws and wide foraminotomies at both levels with partial facetectomies to address the foraminal compromise;

(t) on 27 May 2024, Dr Coughlan reported that the applicant underwent an L4/5 and L5/S1 anterior lumbar interbody fusion;

(u) on 28 May 2024m Dr Coughlan reported that the applicant underwent L4/5 and L5/S1 posterior pedicle screw fixation;

(v) on 30 May 2024, a CT scan of the lumbar spine was reported to show moderate to severe left foraminal stenosis at L5/S1 with loss of the normal fat plane surrounding the nerve root suggesting left L5 nerve impingement. Moderate left foraminal narrowing at L4/5 potentially impinging the left L4, moderate to severe canal stenos at L3/L4 level, a right posterior dominant disc osteophyte complex, with narrowing of the right subarticular recess at L5/S1 and severe right foraminal stenosis;

(w) on 7 June 2024, an MRI of the lumbar spine was reported to show no complicating features post fusion of L4 to S1, mild diastasis of bilateral L4/5 facet joints with effusion, right posterior osteophyte at L5/S1 causing lateral recess stenosis and potential impingement of right S1 nerve and mild constitutional lumbar canal stenosis;

(x) on 13 June 2024, Dr Coughlan reported that he was concerned with the applicant's ongoing foot drop which had not improved. Dr Coughlan noted that the MRI scan showed the L4/5 facet rather diastased, which Dr Coughlan suspected may be causing some ongoing compression of the left L5 nerve root within the L4/5 lateral recess. Dr Coughlan stated that, given the applicant's ongoing foot drop, it was possible that that was a consequence of the longevity of his nerve compression but, for the sake of thoroughness, he suggested urgently re-exploring the L5 nerve on the left side, focusing on the L4/5 interspace and lateral recess and also the L5/S1 foramen;

(y) on 25 June 2024, Dr Coughlan reported that the applicant underwent re-exploration of the L5 nerve on the left side, focusing on the L4/5 interspace and lateral recess and also the L5/S1 foramen;

(z) on 18 July 2024, a CT scan of the lumbar spine was reported to show no evidence of hardware failure following the posterior and anterior fusion, with progressive left L3 extra foraminal compression;

(aa) on 9 August 2024, Dr Coughlan reported that, since the two-level anterior fusion with posterior screws, the applicant had noticed a marked improvement in his back pain, however he continued to suffer from persistent left-sided foot drop and very weak tibialis anterior, which had been a long-standing issue. Dr Coughlan requested an updated MRI. Dr Coughlan stated that the applicant may have some lateral recess stenosis at the level above his fusion at L3/4;

(bb) on 12 August 2024, an MRI of the lumbar spine was reported to show: at the L3/L4 level, diffuse posterior disc bulge with mild thecal sac compression and bilateral mild foraminal encroachment due to bulging disc and facet arthropathy; at the L4/L5 level, prior fusion and left hemilaminectomy, possibly a small synovial cyst arising from the left facet joint that may encroach on the left exit foramen causing mild to moderate foraminal encroachment without neural compromise, with no significant right foraminal encroachment seen; at the L5/S1 level, posterior disc osteophytic changes with minimal canal encroachment, mild to moderate foraminal encroachment and mild lateral recess stenosis with potential minimal encroachment of the descending S1 nerve roots (right more than left), which were similar to the previous study;

(cc) on 16 August 2024, Dr Coughlan reported that recent MRI showed that there may be some evidence of L3/4 stenosis and that compression could account for the applicant's persistent foot drop. Dr Coughlan recommended that the applicant undergo nerve conduction studies to exclude a common peroneal nerve palsy before they consider surgical options;

(dd) on 27 September 2024, Professor Heard, neurologist, reported that findings of a further nerve conduction study were very similar to the previous study of April 2024, with the left tibial motor response being absent, with preserved sural sensory responses. Professor Heard concluded that the findings were more in keeping with lumbar nerve root disease, although incomplete sciatic nerve lesion could not be entirely excluded;

(ee) on 4 November 2024, Dr Coughlan reported that the applicant had persistent left-sided foot drop and no improvement in strength, although his pain had improved. Dr Coughlan noted that an MRI scan showed a synovial cyst at L4/5 potentially irritating the left L4 nerve root. Dr Coughlan stated that it was difficult to know whether the lack of improvement was from a chronic neuropraxia and will not improve or whether there was still an ongoing issue affecting the left L4/L5 nerve. He noted that the L5 nerve looked very free and capacious, however on the left L4 nerve there was a far lateral cyst compressing left L4 nerve root. Dr Coughlan recommended and requested a stereotactic guided left L4/5 stereotactic guided bilateral foraminotomy to decompress the nerve in the far lateral;

(ff) also on 4 November 2024, Dr Coughlan estimated that his costs to perform stereotactic guided left L4/5 far lateral foraminotomy was $8,160;

(gg) on 3 February 2025, Dr Coughlan reported that, whilst the applicant had minimal back pain, he was concerned regarding the applicant's chronic foot drop and the atrophy in the gastrocnemius and tibialis anterior, which was impacting the applicant's overall gait and instability. Dr Coughlan recommended getting nerve conduction studies as well as an EMG and review by Professor Heard;

(hh) on 5 March 2025, Professor Heard, neurologist, who noted a history that the applicant reported that his left foot drop appeared subacutely after the accepted injury and slowly worsened, and that three nerve conduction studies had shown stable findings, with no focal abnormality of the left common peroneal nerve and the sural response was preserved. Professor Heard noted that nerve conduction studies were again unchanged from the previous studies. On examination, Professor Heard noted marked wasting of the left tibialis anterior and mild wasting of the posterior left calf muscles and severe weakness of left ankle dorsiflextion and inversion and mild weakness of left ankle plantar flexion, reduced left knee jerk, absent left ankle jerk, and loss of feeling over the left hallux and hypersensitivity over the lateral calf indicative of L5, although the right leg and upper limbs examined normally. Professor Heard opined that the findings are consistent with radicular pathology, mainly at L5 but also including L4 and S1 on the left, with a differential diagnosis of a high sciatic trunk lesion involving selectively the peroneal component of the sciatic trunk;

(ii) on 6 March 2025, Professor Heard, neurologist, reported that recent further nerve conduction studies were very similar to previous studies and were in keeping with lumbar nerve root disease, and

(jj) on 14 March 2025, Dr Coughlan reported that the left side of the applicant's trunk had progressively worsened. Dr Coughlan stated that the applicant had been reviewed by Professor Heard, who pointed out that the three nerve conduction tests had been essentially consistent and pointed towards a nerve root issue in the lumbar spine. Dr Coughlan reported that the applicant had a stable fusion, which had certainly helped his axial back pain. Dr Coughlan reported that the applicant had a synovial cyst at L4/5 which was potentially compressing the L4 nerve within the foramen, and he also had some residual hypertrophic facet joint disease at L5/S 1 which was potentially compressing the L5 nerve root within the foramen. Clinically, Dr Coughlan suspected that the applicant's profound foot drop and progressive foot drop was from the L4 and L5 radicular compression.

Dr Coughlan stated that requires a partial facetectomy to completely decompress the nerve roots within the course of the exit foramen where the compression was, noting that the compression was not so much within the canal, but behind the facet joints and within the neural foramina. Dr Coughlan noted that the CT scan showed some residual facet arthropathy at L4/5 on the left hand side, which was potentially compressing the L4 nerve root in the preforaminal area and foraminal area. Dr Coughlan expressed concern in relation to the ongoing delay, the progression of the applicant's foot drop, the longevity of his foot drop, and the profound impact that was going to have on his gait and his stability and his risk of falls. Given the applicant's ongoing deterioration in terms of nerve function,

Dr Coughlan recommended expediting the decompression.

Dr Caroline Tan, neurosurgeon, independent medical expert qualified by the respondent

(a) reported on her examination of the applicant on 16 December 2024 and review of relevant material including imaging;

(b) recorded a detailed history of injury and subsequent treatment;

(c) recorded that the applicant's current symptoms were constant central low back pain, random spasms in the left foot, the left foot "feels like cardboard" and there is dense numbness in the left shin;

(d) recorded that the applicant's current treatment is physiotherapy and pain medication;

(e) on examination, noted that the applicant walked with a wheelie-walker, had zero power of left ankle dorsiflexion, left foot eversion and of the extensor hallucis longus, however power of left knee flexion and extension was normal, there was bilaterally depressed deep tendon reflexes in both limbs and severe numbness to light touch in the anterolateral left leg;

(f) diagnosed permanent left L5 nerve root injury;

(g) expressed the opinion that "the diagnosis of permanent left L5 nerve injury is attributable to the work injury that occurred on 1 March 2022, although Dr Anil's report does record that the symptoms worsened after the work injury on 1 March 2022, so there may have been subsequent injury after 1 March 2022";

(h) stated that:

"Subject to the qualification that I do not have sufficient information to confirm that his foot drop was complete from 1 March 2022, I believe that his employment and, more specifically, the incident on 1 March 2022 are the cause of the persistent weakness and numbness in the left lower limb, which is entirely consistent with a diagnosis of permanent left L5 nerve root injury. The description of the incident would provide for a mechanism of injury where the left L5 nerve was severely contused and internally disrupted (axonotmesis). If Dr Heard had performed needle EMG, this could have confirmed the diagnosis of left L5 nerve injury and also indicated the poor prognosis for recovery. Mr Bridge stated that the foot weakness was present from the time of the work incident and I am assuming that is true. The gas in the L5/S 1 disc means that the segment was mobile and he could potentially have had further injury to the nerve after the work incident. Furthermore, Mr Bridge and Dr Coghlan have stated that the foot weakness did not alter at all despite the many surgeries he has undergone";

(i) in relation to recommended treatment, stated:

"In terms of the foot weakness, it is my opinion that further spinal surgery is futile. First of all, the original injury could have been of a severity that recovery of the foot weakness was never realistically going to occur. He would have had the best chance of recovery if he had presented to a neurosurgeon immediately upon noticing severe foot drop. However,

Mr Bridge presented late to a neurosurgeon with his foot drop and by then whatever prospects of motor recovery were probably dashed. After nearly three years of complete left foot drop, the very remote possibility that his foot drop will ever recover now could be confirmed by referring him to a neurologist to perform needle EMG. If the needle EMG shows no regenerating axons then it is extremely unlikely that he will experience any recovery of the foot weakness. In that event, the only treatment that I think could be of substantive value, would be functional restoration through nerve or tendon transfers. A plastic surgeon with expertise, skill and knowledge in this area of functional restoration would have to be consulted about whether tendon or nerve transfer would be feasible and worthwhile.

In terms of the back pain, this could be due to his underlying degenerative spinal disease and/or tissue trauma and adjacent segment strain from his fusion surgery. There is no surgery that can reliably relieve such axial pain so he would be best advised to manage this conservatively. An exercise physiologist has already provided him with guidance on how to reduce loading of his lumbar spine but he may also get benefit from a period of exercise sessions with an exercise physiologist. The input of a pain management specialist may be helpful with respect to pharmacological therapies. He may also undergo a pain management program.

Advice about the exact treatment type, frequency and duration will have to be obtained from the treating health practitioners";

(j) expressed the opinion that the treatment proposed by Dr Coughlan was not recommended for the reasons set out above;

(k) expressed the opinion that there would be no benefit from further spinal surgery;

(l) in relation to the treatment proposed by Dr Coughlan, stated that:

"The proposed surgery is not expected to assist with his recovery from any work-related injury, for reasons already given. It would be decompressing the left L4 nerve which is not a cause for severe left foot drop and it would also be treating a pathology that was not present in the earlier postoperative MRIs so the left L4 nerve was not affected by the work incident", and

(m) in relation to alternative treatment, stated that:

"In his current state, if needle EMG confirms axonotmesis or other permanent injury to the left L5 nerve, and given his constant significant back pain, he will not be able to return to suitable employment now or into the future, unless he should undergo successful functional restoration surgery by a plastic surgeon. However, even if he undergoes functional restoration surgery, the timeframe for recovery and full realisation of the benefits of that surgery is in the order of 1 -2 years by which time he will be nearly 60 years age so there is considerable uncertainty about his prospects for return to work."

Dr Peter Spittaler, neurosurgeon, independent medical expert qualified by the applicant

(a) reported on his examination of the applicant on 14 April 2025 and review of relevant material including imaging;

(b) recorded a detailed history of injury and subsequent treatment;

(c) noted that the applicant reported constant lower back pain and left calf pain and persisting weakness in the left foot;

(d) noted that the applicant's current treatment included physiotherapy and pain relief;

(e) on examination, noted that there was evidence of a left L5 radiculopathy with weakness and sensory disturbance, which included that the applicant used a wheelie-walker, there was mild tenderness in the paraspinal muscles, extension of the lumbar spine was limited by left-sided lower back pain, there was a complete left sided foot drop and the left calf measured approximately 1.5 cm less than the right calf, ankle jerks were absent bilaterally, there was reduced sensation in the lateral calf and dorsum of the foot on the left side;

(f) diagnosed lumbar spondylosis, specifically L4/5 and L5/S1 degenerative disc disease and subsequent foraminal stenosis and nerve root compression with a left foot drop;

(g) gave a poor prognosis for relief of the applicant's back pain and left foot weakness and foot drop;

(h) expressed the opinion that the applicant had pre-existing asymptomatic lumbar disc degeneration most severe at L5/S1 but also present at L4/5, which had been exacerbated and rendered symptomatic by the accepted injury in March 2022;

(i) in relation to the treatment proposed by Dr Spittaler, stated:

"On my viewing of the imaging there appears to be some foraminal stenosis laterally from the pathology I have described in the investigations and on that basis I think repeat surgery would be worthwhile. That being said I do not think that a left L4/5 foraminotomy which would decompress the L4 nerve root is likely to have a major impact on the foot weakness although it is possible; weakness of dorsiflexion usually occurs with an L5 nerve root lesion which occurs from L5/S1 foraminal stenosis but this notwithstanding it is possible there is a contribution to the weakness from the L4 nerve root";

(j) in relation to the cause of the need for the treatment, Dr Spittaler expressed the opinion that:

"Either the employment or the treatment for the injury sustained from the employment may be leading to the foraminal stenosis. The foraminal stenosis appears to have developed since the interbody fusion surgery and it is possible there has been a subluxation of the facet joint which has led to the foraminal stenosis developing. It certainly did not appear to be there on the CT scan from March 2024", and

(k) in relation to the report of Dr Tan dated 21 December 2024, Dr Spittaler stated that:

"I do not know that I would describe 'further spinal surgery as futile'. In essence I think it is likely Mr Bridge will have a permanent L5 root lesion. I think there is a possibility that decompressing the L4 root could lead to some improvement although as I have stated above L4 is not usually the major root supply to the tibialis anterior (which is the dorsiflexor of the foot). Nevertheless it often does provide some supply so there may be some improvement in the weakness. There is certainly definitely evidence of foraminal stenosis laterally in the foramen so I can understand why

Dr Coughlan is suggesting the treatment; given the significant neurological deficit I think it is prudent, wise and appropriate to 'pull out all stops' to try and improve the situation. Nevertheless given the length of time and the entrenched changes on electrophysiology I think the likelihood of success is not great but it is possible. In short, if I were Mr Bridge I would want everything done to try and improve the weakness. On that basis I do not think that the surgery should be denied and certainly there is nothing else to do apart from wearing a splint to overcome the weakness. Another point I would make is that the surgery proposed by Dr Coughlan is not a major procedure and is very unlikely to make things worse."

1. Counsel's submissions were made orally during the hearing and were recorded and have been considered in full. I am grateful to counsel for their assistance in this matter.
2. In summary, on behalf of the applicant, Mr McMahon:

(a) relied on the principles enunciated by Burke CCJ in Bartolo v Western Sydney Area Health Service,[1] that in determining whether a medical treatment will be reasonably necessary, if it is better that he have it, then it is necessary and should not be forborne;

(b) submitted that the medical evidence, in particular that of Dr Spittaler and Dr Tan, demonstrates that the treatment is prudent, wise and appropriate, should not be denied, is unlikely to make things worse;

(c) submitted that no viable alternative treatments have been identified;

(d) submitted that the applicant's statement shows how the applicant used a splint which he found uncomfortable and provided no stability and now he uses a walking stick;

(e) submitted that the proposition the accepted injury did not involve the left L4 nerve (which derives from Dr Tan's report) is not determinative of the issue of whether the treatment is reasonably necessary as a result of the injury;

(f) submitted that Dr Spittaler's opinion is that the treatment or the employment may be leading to the foraminal stenosis, and on that basis, there is a causal link between the employment and worsening of the applicant's symptoms which has been evidenced by the applicant, and

(g) submitted that the treatment is the only reasonably treatment option with any potential effectiveness and it is reasonably necessary as a result of the accepted injury.

1. In summary, on behalf of the respondent, Mr Necovski:

(a) submitted that the applicant has not discharged the onus of proof and has not established that the treatment is reasonably necessary as a result of the accepted injury, and the evidence is a wholly undesirable basis to make an order for compensation pursuant to s 60 of the 1987 Act;

(b) submitted that the medical evidence demonstrates that the treatment targets the wrong nerve root, and that the treatment is unlikely to result in any significant improvement in the applicant's condition;

(c) submitted that the pathology targeted by the treatment is unrelated to the accepted injury;

(d) submitted that the evidence does not establish any basis upon which the test in Diab is satisfied because there is consistent evidence that the treatment is not expected to improve the applicant's foot drop which is expected to be permanent, Dr Tan proposed an alternative treatment of tendon or nerve transfers which has not been properly considered, the cost is excessive to engage in an endeavour where there is slim to no chance of effectiveness, the treatment is speculative and is not likely to be effective;

(e) submitted that the treatment is against the applicant's interests, will not benefit him and it may be better for him to explore the alternative treatments proposed by Dr Tan, and

(f) submitted that the Commission should make an award for the respondent.

1. In summary, on behalf of the applicant in reply, Mr McMahon:

(a) submitted that the Commission should prefer and accept the evidence of

Dr Spittaler that the accepted injury or employment with the respondent led to foraminal stenosis and that is the basis for the treatment, that there is a chance of a benefit to the applicant of having the treatment, that it is better that the applicant have the treatment than not have the treatment, that the characterisation of the applicant's condition as permanent is not supported by the evidence, and that the respondent has not adduce evidence that the alternative treatments proposed by Dr Tan are appropriate and anything more than options to be considered.

1. Section 60 of the 1987 Act relevantly provides:

"60 Compensation for cost of medical or hospital treatment and rehabilitation etc

(1) If, as a result of an injury received by a worker, it is reasonably necessary that:

(a) any medical or related treatment (other than domestic assistance) be given, or

(b) any hospital treatment be given, or

(c) any ambulance service be provided, or

(d) any workplace rehabilitation service be provided,

the worker's employer is liable to pay, in addition to any other compensation under this Act, the cost of that treatment or service and the related travel expenses specified in subsection (2)."

1. Burke CCJ in Rose v Health Commission (NSW),[2] stated:

"...Treatment is necessarily purposive. Treatment, in the medical or therapeutic context, relates to the management of disease, illness or injury by the provision of medication, surgery or other medical service designed to arrest or abate the progress of the condition or to alleviate, cure or remedy the condition. It is the provision of such services for the purpose of limiting the deleterious effects of a condition and restoring health. If the particular 'treatment' cannot, in reason, be found to have that purpose or be competent to achieve that purpose, then it is certainly not reasonable treatment of the condition and is really not treatment at all. In that sense, an employer can only be liable for the cost of reasonable treatment..." (my emphasis)

1. In Diab v NRMA Ltd,[3] Roche DP, referring to the decision in Rose v Health Commission (NSW),[4] set out the test for determining if medical treatment is reasonably necessary as a result of a work injury_:_

"The standard test adopted in determining if medical treatment is reasonably necessary as a result of a work injury is that stated by Burke CCJ in Rose v Health Commission (NSW) [1986] NSWCC2; [1986] NSWCC 2; (1986) 2 NSWCCR 32 (Rose) where his Honour said, at 48A-C:

1. Any necessity for relevant treatment results from the injury where its purpose and potential effect is to alleviate the consequences of injury.
2. It is reasonably necessary that such treatment be afforded a worker if this Court concludes, exercising prudence, sound judgment and good sense, that it is so. That involves the Court in deciding, on the facts as it finds them, that the particular treatment is essential to, should be afforded to, and should not be forborne by, the worker.
3. In so deciding, the Court will have regard to medical opinion as to the relevance and appropriateness of the particular treatment, any available alternative treatment, the cost factor, the actual or potential effectiveness of the treatment and tis place in the usual medical armoury of treatments for the particular condition."
4. Roche DP also noted that the Commission has generally referred to and applied the decision of Burke CCJ in Bartolo v Western Sydney Area Health Service:[5]

"The question is should the patient have this treatment or not. If it is better that he have it, then it is necessary and should not be forborne. If in reason it should be said that the patient should not do without this treatment, then it satisfies the test of being reasonably necessary."

"In the context of s 60 the relevant matters, according to the criteria of reasonableness, include, but are not necessarily limited to, the matters noted by Burke CCJ at point (5) in Rose (see [76] above), namely:

(b) the appropriateness of the particular treatment;

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

(d) the cost of the treatment;

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

(f) the acceptance by medical experts of the treatment as being appropriate and likely to be effective.

With respect to point (d), it should be noted that while the effectiveness of the treatment is relevant to whether the treatment was reasonably necessary, it is certainly not determinative. The evidence may show that the same outcome could be achieved by a different treatment, but at a much lower cost. Similarly, bearing in mind that all treatment, especially surgery, carries a risk of a less than ideal result, a poor outcome does not necessarily mean that the treatment was not reasonably necessary. As always, each case will depend on its facts."

Is the treatment reasonably necessary as a result of injury?

1. A commonsense evaluation of the causal chain is required. The applicable legal test of causation was set out by the Court of Appeal in Kooragang,[6] where Kirby P (as his Honour then was) stated:

"From the earliest days of compensation legislation, it has been recognised that causation is not always direct and immediate...

Since that time, it has been well recognised in this jurisdiction that an injury can set in train a series of events. If the chain is unbroken and provides the relevant causative explanation of the incapacity or death from which the claim comes, it will be open to the Compensation Court to award compensation under the Act."[7]

"The result of the cases is that each case where causation is in issue in a workers' compensation claim, must be determined on its own facts. Whether death or incapacity results from a relevant work injury is a question of fact. The importation of notions of proximate cause by the use of the phrase 'results from', is not now accepted. By the same token, the mere proof that certain events occurred which predisposed a worker to subsequent injury or death, will not, of itself, be sufficient to establish that such incapacity or death 'results from' a work injury. What is required is a commonsense evaluation of the causal chain. As the early cases demonstrate, the mere passage of time between a work incident and subsequent incapacity or death, is not determinative of the entitlement to compensation. In each case, the question whether the incapacity or death 'results from' the impugned work injury (or in the event of a disease, the relevant aggravation of the disease), is a question of fact to be determined on the basis of the evidence, including, where applicable, expert opinions. Applying the second principle which Hart and Honoré identify, a point will sometimes be reached where the link in the chain of causation becomes so attenuated that, for legal purposes, it will be held that the causative connection has been snapped. This may be explained in terms of the happening of a novus actus. Or it may be explained in terms of want of sufficient connection. But in each case, the judge deciding the matter, will do well to return, as McHugh JA advised, to the statutory formula and to ask the question whether the disputed incapacity or death 'resulted from' the work injury which is impugned."

1. Although the High Court in Comcare v Martin[8] raised some concerns about the commonsense evaluation of the causal chain in a matter that concerned Commonwealth legislation, the commonsense approach still has place in the application of the legislation to the present case.
2. The work injury does not have to be the only, or even a substantial, cause of the need for the relevant treatment before the cost of that treatment is recoverable under s 60 of the 1987 Act - it is only necessary to establish that the injury materially contributed to the need for the treatment. In Murphy v Allity Management Services Pty Ltd,[9] Roche DP stated at [57] and [58] that:

"57. The work injury does not have to be the only, or even a substantial, cause of the need for the relevant treatment before the cost of that treatment is recoverable under s 60 of the 1987 Act.

1. Ms Murphy only has to establish, applying the commonsense test of causation (Kooragang Cement Pty Ltd v Bates (1994) 35 NSWLR 452; 10 NSWCCR 796), that the treatment is reasonably necessary "as a result of" the injury (see Taxis Combined Services (Victoria) Pty Ltd v Schokman [2014] NSWWCCPD 18 at [40] - [55]). That is, she has to establish that the injury materially contributed to the need for the surgery (see the discussion on the test of causation in Sutherland Shire Council v Baltica General Insurance Co Ltd (1996) 12 NSWCCR 716)."
2. It is not necessary for the applicant to establish that a consequential condition is itself an 'injury' pursuant to s 4 of the 1987 Act nor that the employment was a substantial contributing factor within the meaning of s 9A of the 1987 Act. In Moon v Conmah Pty Ltd,[10] Deputy President Roche stated at [45]-[46]:[11]

"It is therefore not necessary for Mr Moon to establish that he suffered an 'injury' to his left shoulder within the meaning of that term in section 4 of the 1987 Act. All he has to establish is that the symptoms and restrictions in his left shoulder have resulted from his right shoulder injury. Therefore, to the extent that the Arbitrator and Dr Huntsdale approached the matter on the basis that Mr Moon had to establish that he sustained an 'injury' to his left shoulder in the course of his employment with Conmah they asked the wrong question."

1. In Bouchmouni v Bakhos Matta t/as Western Red Services,[12] Deputy President Roche stated:

"The Commission has considered and explained the difference between an 'injury' and a condition that has resulted from an injury in several recent decisions...

The injury to Mr Bouchmouni's right knee caused him to seek treatment in the form of surgery and physiotherapy. The evidence suggests that it was in the course of receiving that treatment, and/or as a result of an altered gait because of his knee symptoms, Mr Bouchmouni developed back symptoms. If that is accepted, and no reason has been advanced why it should not be, it is clear beyond doubt that his back condition has resulted from the treatment he received for his accepted knee injury and his altered gait. That does not, however, make the back condition an 'injury'."

1. In North Coast Area Health Service v Felstead (Felstead),[13] Roche DP observed at [81]:

"81. It follows that the description of a personal injury as 'a sudden identifiable pathological change' is consistent with the authorities. It suggests no more than that, to qualify as a personal injury, there must be some sudden and ascertainable or dramatic physiological change or disturbance of the normal physiological state. Such a change or disturbance may be as simple as a bruise or a soft tissue strain. If the personal injury also aggravates a pre-existing disease, that does not mean it is no longer a personal injury."

1. The Court of Appeal in Nguyen v Cosmopolitan Homes[14] held that a tribunal of fact must be actually persuaded of the occurrence or existence of the fact before it can be found, and stated:

"(1) A finding that a fact exists (or existed) requires that the evidence induce, in the mind of the fact-finder, an actual persuasion that the fact does (or at the relevant time did) exist;

(2) Where on the whole of the evidence such a feeling of actual persuasion is induced, so that the fact-finder finds that the probabilities of the fact's existence are greater than the possibilities of its non-existence, the burden of proof on the balance of probabilities may be satisfied;

(3) Where circumstantial evidence is relied upon, it is not in general necessary that all reasonably hypotheses consistent with the non-existence of a fact, or inconsistent with its existence, be excluded before the fact can be found, and

(4) A rational choice between competing hypotheses, informed by a sense of actual persuasion in favour of the choice made, will support a finding, on the balance of probabilities, as to the existence of the fact in issue."

1. It is not in dispute that the applicant sustained the accepted injury on or about 1 March 2022.
2. The applicant's evidence, which is consistent with the treating medical evidence and I accept, is that he now suffers from symptoms which include severe and worsening back pain, left leg weakness and left-sided foot drop and foot numbness, and significant functional restrictions, which cause him to regularly stumble and fall, he suffers from a severe antalgic gait and he is now reliant on a walker and/or walking stick for mobility. The applicant wishes to undergo the treatment in the hope that it will provide relief and improve his quality of life.
3. The applicant's treating neurosurgeon, Dr Coughlan, reported on 4 November 2024 that the applicant had persistent left-sided foot drop and no improvement in strength, although his pain had improved since other surgeries. Dr Coughlan noted that an MRI scan showed a synovial cyst at L4/5 potentially irritating the left L4 nerve root. Dr Coughlan considered that it was difficult to know whether the lack of improvement was from a chronic neuropraxia and will not improve or whether there was still an ongoing issue affecting the left L4/L5 nerve. He noted that the L5 nerve looked very free and capacious, however on the left L4 nerve there was a far lateral cyst compressing left L4 nerve root. Dr Coughlan recommended and requested the treatment, being stereotactic guided left a L4/5 stereotactic guided bilateral foraminotomy, to decompress the nerve in the far lateral.
4. On 3 February 2025, Dr Coughlan reported that, whilst the applicant had minimal back pain, he was concerned regarding the applicant's chronic foot drop and the atrophy in the gastrocnemius and tibialis anterior, which was impacting the applicant's overall gait and instability. Dr Coughlan recommended getting nerve conduction studies as well as an EMG and review by Professor Heard.
5. On 5 March 2025, Professor Heard, neurologist, reported that nerve conduction studies were again unchanged from the previous studies. On examination, Professor Heard noted marked wasting of the left tibialis anterior and mild wasting of the posterior left calf muscles and severe weakness of left ankle dorsiflextion and inversion and mild weakness of left ankle plantar flexion, reduced left knee jerk, absent left ankle jerk, and loss of feeling over the left hallux and hypersensitivity over the lateral calf indicative of L5, although the right leg and upper limbs examined normally. Professor Heard opined that the findings are consistent with radicular pathology, mainly at L5 but also including L4 and S1 on the left, with a differential diagnosis of a high sciatic trunk lesion involving selectively the peroneal component of the sciatic trunk.
6. On 14 March 2025, Dr Coughlan reported that the left side of the applicant's trunk had progressively worsened. Dr Coughlan stated that the applicant had been reviewed by Professor Heard, who pointed out that the three nerve conduction tests had been essentially consistent and pointed towards a nerve root issue in the lumbar spine. Dr Coughlan reported that the applicant had a stable fusion, which had certainly helped his axial back pain.

Dr Coughlan reported that the applicant had a synovial cyst at L4/5 which was potentially compressing the L4 nerve within the foramen, and he also had some residual hypertrophic facet joint disease at L5/S 1 which was potentially compressing the L5 nerve root within the foramen. Clinically, Dr Coughlan suspected that the applicant's profound foot drop and progressive foot drop was from the L4 and L5 radicular compression. Dr Coughlan stated that requires a partial facetectomy to completely decompress the nerve roots within the course of the exit foramen where the compression was, noting that the compression was not so much within the canal, but behind the facet joints and within the neural foramina.

Dr Coughlan noted that the CT scan showed some residual facet arthropathy at L4/5 on the left hand side, which was potentially compressing the L4 nerve root in the preforaminal area and foraminal area. Dr Coughlan expressed concern in relation to the ongoing delay, the progression of the applicant's foot drop, the longevity of his foot drop, and the profound impact that was going to have on his gait and his stability and his risk of falls. Given the applicant's ongoing deterioration in terms of nerve function, Dr Coughlan recommended expediting the decompression. 7. I am satisfied that the above evidence demonstrates that the applicant has ongoing symptoms which included pain, but is primarily left-sided foot drop. The applicant's treating neurosurgeon, Dr Coughlan, has explained that recent MRI scan showed a synovial cyst at L4/5 which is compressing the left L4 nerve root and opines that such radicular pathology could be the cause of the applicant's ongoing symptoms and that the treatment may provide relief.

The availability of alternative treatment, and its potential effectiveness

1. In relation to the applicant's left-sided foot drop, based on her opinion that the applicant had an L5 injury, Dr Caroline Tan, neurosurgeon, independent medical expert, recommended that the applicant be referred to a neurologist to perform needle electromyography (EMG) to confirm axonotmesis or other permanent injury to the left L5 nerve, and the prognosis for recovery of the applicant's left-sided foot drop. Dr Tan stated that if the needle EMG shows no regenerating axons then it is extremely unlikely that the applicant will experience any recovery of the foot weakness.
2. Dr Tan stated that, the only treatment that could potentially be of substantive value to assist the applicant's left-sided foot drop would be functional restoration through nerve or tendon transfers. Dr Tan noted that the timeframe for recovery and full realisation of the benefits of functional restoration surgery is in the order of one to two years by which time he will be nearly 60-year-old so there is considerable uncertainty about his prospects for return to work.
3. In any event, I note that at this point in time there remains significant questions as to whether such surgery would be likely to be effective to treat the applicant's left-sided foot drop, because as Dr Tan stated, it is firstly subject to the findings of an EMG and secondly, subject to the opinion of a suitable plastic surgeon about whether tendon or nerve transfer would be feasible and worthwhile.
4. In relation to the applicant's pain, Dr Tan expressed the opinion that there would be no benefit from further spinal surgery. Dr Tan expressed the opinion that there is no surgery that can reliably relieve the applicant's axial pain, which she believes was due to his underlying degenerative spinal disease and/or tissue trauma and adjacent segment strain from his fusion surgery. On that basis, Dr Tan recommended that the applicant undergo a period of exercise sessions with an exercise physiologist, receive input of a pain management specialist with respect to pharmacological therapies and may also undergo a pain management program.
5. Dr Spittaler expressed the opinion that certainly there is nothing else to do apart from wearing a splint to overcome the left-sided weakness.
6. I note that the treating evidence shows that the applicant has undergone various conservative treatment to date including sessions with an exercise physiologist to teach him how to manage the axial load, physiotherapy and pain relief. However, they have not provided the applicant with any substantial nor enduring relief from the ongoing symptoms.
7. The applicant's evidence, which I accept, is that he has tried a splint to assist with mobility however it was uncomfortable, unsupportive and his foot twisted and still felt very unstable, and that even work boots do not provide sufficient stability.
8. Based on the applicant's significant medical history to date, I am not satisfied that conservative treatment will provide any significant relief of his left-sided foot drop and back pain.
9. It appears from the evidence that no specific alternative treatment has been identified at this time which is clearly likely to be effective to treat the applicant's left-sided foot drop and back pain. As noted by Dr Tan, further investigation is possible however there is no clear indication that it will result in treatment which will likely assist the applicant.

1. Dr Coughlan estimated that his costs to perform stereotactic guided left L4/5 far lateral foraminotomy was $8,160.
2. There is no medical evidence which challenges that estimate.

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

1. Dr Caroline Tan, neurosurgeon, independent medical expert qualified by the respondent, diagnosed permanent left L5 nerve injury, stating that the persistent weakness and numbness in the applicant's left lower limb, was entirely consistent with such an injury.

Dr Tan expressed the opinion that the treatment would be futile to provide any relief to the applicant because:

(a) the original injury could have been of a severity that recovery of the foot weakness was never realistically going to occur;

(b) the applicant presented late to a neurosurgeon with his foot drop and by then whatever prospects of motor recovery were probably dashed, and

(c) the treatment would be decompressing the left L4 nerve which she did not believe was a cause of the applicant's severe left foot drop.

1. I note that Dr Tan did not significantly address Dr Coughlan's opinion regarding the possibility of foraminal stenosis laterally in the foramen and the potential that L4 often does provide some supply to the tibialis anterior.
2. Dr Spittaler, neurosurgeon, independent medical expert qualified by the applicant, diagnosed lumbar spondylosis, specifically L4/5 and L5/S1 degenerative disc disease and subsequent foraminal stenosis and nerve root compression with a left foot drop. Dr Spittaler noted that there was evidence of a left L5 radiculopathy with weakness and sensory disturbance, a complete left sided foot drop and the left calf measured approximately 1.5 cm less than the right calf, ankle jerks were absent bilaterally, there was reduced sensation in the lateral calf and dorsum of the foot on the left side.
3. In relation to the treatment, Dr Spittaler stated that he did not believe that a left L4/5 foraminotomy which would decompress the L4 nerve root was likely to have a major impact on the foot weakness, because weakness of dorsiflexion usually occurs with an L5 nerve root lesion which occurs from L5/S1 foraminal stenosis. Dr Spittaler accepted that it is likely that the applicant will have a permanent L5 root lesion.
4. Dr Spittaler accepted that whilst L4 is not usually the major root supply to the tibialis anterior (which is the dorsiflexor of the foot), however he stated that L4 nevertheless often does provide some supply to the tibialis anterior.
5. However, Dr Spittaler, did not accept that the treatment is futile. Dr Spittaler opined that because L4 often does provide some supply to the tibialis anterior, there is a possibility that decompressing the L4 root could lead to some improvement in the applicant's symptoms.
6. Further, Dr Spittaler acknowledged that there is certainly definitely evidence of foraminal stenosis laterally in the foramen so he could understand why Dr Coughlan suggested the treatment.
7. Dr Spittaler opined that, the likelihood of success of the treatment is not great but it is possible, and that given the significant neurological deficit, it is prudent, wise and appropriate that the applicant undergo the treatment. On that basis, Dr Spittaler opined that the treatment should not be denied, noting that the treatment is not a major procedure and is very unlikely to make things worse.
8. I note that Dr Coughlan has been actively engaged in the applicant's treatment since the accepted injury and has performed various surgeries that the applicant has undergone to date as a result of the accepted injury. Dr Coughlan has regularly reported on the applicant's progress, symptoms and restrictions over time and has noted the development and significant deterioration of symptoms, particularly the left-sided foot drop. Dr Coughlan has provided various opinions over time regarding the cause and appropriate treatment for those symptoms.
9. It is somewhat difficult to reconcile the competing medical opinions.
10. However, I consider that Dr Coughlan has a thorough understanding and appreciation of the applicant's clinical condition and the underlying pathology, developed over time since the accepted injury. Further and significantly, I consider that Dr Coughlan has provided a thorough and logical explanation for his opinion regarding the reasonable need for the treatment.
11. Considering the statutory provisions, the case law and the evidence as a whole, and for all of the reasons that I have set out above, I prefer and accept the opinions of Dr Coughlan and Dr Spittaler. I consider that their opinions provide a logical and persuasive basis for the applicant to undergo the treatment.
12. On that basis, and having regard to the nature of the applicant's ongoing symptoms, I am satisfied that the treatment should be afforded to, and should not be forborne by, the applicant.
13. Accordingly, I accept that the treatment is reasonably necessary.

Is the treatment reasonably necessary as a result of the injury?

1. It appears from the evidence that the applicant significantly recovered from lumbar spine L5/S1 surgery in 2005 to the extent that prior to the accepted injury, he was without any significant physical restrictions and working full-time in physical jobs.
2. The applicant's evidence, which is consistent with treating medical evidence, and I accept, is that the symptoms of severe and worsening back pain, left leg weakness and left-sided foot drop and foot numbness developed subsequent to the accepted injury. It is clear from the medical evidence that the applicant has undergone various treatment, including surgeries, to treat the accepted injury.
3. In relation to the cause of the need for the treatment, Dr Coughlan expressed the opinion that either the employment or the treatment for the injury sustained from the employment may be leading to the foraminal stenosis. Dr Coughlan noted that the foraminal stenosis did not appear to be there on the CT scan from March 2024 and that it appeared to have developed since the interbody fusion surgery and that it was possible that there has been a subluxation of the facet joint which has led to the foraminal stenosis developing.
4. Turning to the independent medical evidence, Dr Tan expressed the opinion that her diagnosis of permanent left L5 nerve injury is attributable to the accepted injury, although she mentioned the possibility of a subsequent injury, noting that the applicant's symptoms of left-sided foot drop worsened after the accepted injury.
5. Dr Tan accepted that the description of the incident giving rise to the accepted injury would provide for a mechanism of injury where the left L5 nerve was severely contused and internally disrupted (axonotmesis), noting that the applicant reported that the left foot weakness was present from the time of the accepted injury. However, Dr Tan did not accept that the left L4 nerve was the cause for the applicant's severe left foot drop which required treatment and further that the left L4 nerve was affected by the accepted injury.
6. As stated above, I note that Dr Tan did not significantly address Dr Coughlan's opinion regarding the possibility of foraminal stenosis laterally in the foramen and the potential that L4 often does provide some supply to the tibialis anterior.
7. Dr Spittaler expressed the opinion that the applicant had pre-existing asymptomatic lumbar disc degeneration most severe at L5/S1 but also present at L4/5, which had been exacerbated and rendered symptomatic by the accepted injury.
8. In Usher v Coffs Harbour City Council [2022] NSWPICPD 9, at [76], Wood DP, accepted the conclusion that, in the face of the accepted medical evidence in that case, the occurrence of symptoms since the injury did not necessitate a conclusion that the injury materially contributed to the need for surgery. Further, at [77], Wood DP accepted that it was appropriate, in the circumstances of that case, for the Member to focus attention on whether symptoms sought to be addressed by the surgery were referrable to the injury.
9. Again, it is somewhat difficult to reconcile the competing medical opinions.
10. Dr Coughlan has been actively engaged in the applicant's treatment since the accepted injury and has performed various surgeries that the applicant has undergone to date as a result of the accepted injury. Dr Coughlan has regularly reported on the applicant's progress, symptoms and restrictions over time and has noted the development and significant deterioration of symptoms, particularly the left-sided foot drop. Dr Coughlan has provided various opinions over time regarding the cause and appropriate treatment for those symptoms.
11. However, I consider that Dr Coughlan has a thorough understanding and appreciation of the applicant's clinical condition and the underlying pathology, developed over time since the accepted injury. Further and significantly, I consider that Dr Coughlan has provided a thorough and logical explanation for his opinion regarding the reasonable need for the treatment.
12. Considering the statutory provisions, the case law and the evidence as a whole, and for all of the reasons that I have set out above, I prefer and accept the opinions of Dr Coughlan and Dr Spittaler. I consider that their opinions provide a logical and likely explanation for the cause of the applicant's symptoms and the need for the applicant to undergo the treatment.
13. On that basis, and having regard to the nature of the applicant's ongoing symptoms, and applying a commonsense evaluation to the evidence, I am satisfied on the balance of probabilities and find that the necessary causal connection exists and that the treatment is reasonably necessary as a result of the accepted injury.

1. For all the reasons set out above, I find as follows:

(a) the stereotactic guided left L4/5 far lateral foraminotomy requested by

Dr Coughlan is reasonably necessary treatment as a result of the injuries, pursuant to s 60 of the 1987 Act.

(a) in accordance with s 60 of the 1987 Act_,_ the respondent to pay the past costs of and incidental to stereotactic guided left L4/5 far lateral foraminotomy requested by Dr Coughlan.

[1] [1997] NSWCC 1; 14 NSWCCR 233.

[2] [1986] NSWCC2; [1986] NSWCC 2; (1986) 2 NSWCCR 32.

[3] [2014] NSWWCCPD 72.

[4] [1986] NSWCC2; [1986] NSWCC 2; (1986) 2 NSWCCR 32.

[5] [1997] NSWCC 1; 14 NSWCCR 233.

[6] (1994) 35 NSWLR 452; 10 NSWCCR 796.

[7] Kooragang, at [461] (Sheller and Powell JJA agreeing).

[8] [2016] HCA 43, at [42].

[9] [2015] NSWWCCPD 49.

[10] [2009] NSWWCCPD 134.

[11] See also Kumar v Royal Comfort Bedding Pty Ltd [2012] NSWWCCPD 8, at [61].

[12] [2013] NSWWCCPD 4.

[13] [2011] NSWWCCPD 51.