Pursuant to s 7.26(6) of the Motor Accident Injuries Act 2017 (NSW), the Review Panel determines:

1. The certificate of Medical Assessor Alexander Woo dated 15 January 2025 is affirmed**.**
2. The following injuries were caused by the motor accident of 24 October 2021:

(a) cervical spine - C6 spinous process fracture;

(b) lumbar spine - soft tissue injury;

(c) left shoulder - soft tissue injury, and

(d) right shoulder - soft tissue injury.

1. The degree of permanent impairment resulting from the injuries caused by the motor accident is 11% whole person impairment.
2. No deduction is to be applied under cl 6.31 of the Motor Accident Guidelines in respect of any pre-existing condition.
3. The claimant's degree of permanent impairment for the injuries caused by the motor accident exceeds 10% for the purposes of s 7.23(2)(b) of the Motor Accident Injuries Act 2017 (NSW).

1. The claimant, Mr Slobodan Dragicevic, was injured in a motor vehicle accident that occurred on 24 October 2021. Mr Dragicevic was the driver of a Nissan X-Trail SUV and was stationary at a set of traffic lights when his vehicle was struck from behind by another vehicle fitted with a bull bar. At the time of the accident, Mr Dragicevic was restrained by a seatbelt and accompanied by his wife in the front passenger seat. Following the collision, he reported immediate onset of neck and bilateral shoulder pain, with paraesthesia affecting his limbs. He was later taken to Liverpool Hospital, where a C6 spinous process fracture was identified by CT scan.
2. The insurer, Insurance Australia Limited t/as NRMA, accepts liability for statutory benefits under the Motor Accident Injuries Act 2017 (NSW) (the MAI Act).
3. A dispute has arisen as to whether the permanent impairment resulting from the injuries sustained in the accident exceeds the 10% whole person impairment (WPI) threshold for the purposes of s 7.23(2)(b) of the MAI Act. The claimant contends that the threshold is exceeded, relying on reports assessing WPI of up to 21%. The insurer disputes that the injuries give rise to greater than 10% WPI and contends that many of the findings reflect degenerative changes not causally related to the motor accident.
4. The matter was previously referred for medical assessment under s 7.23 of the MAI Act, and Medical Assessor Alexander Woo (the Medical Assessor) issued a certificate on

15 January 2025 assessing WPI at 11%, concluding that injuries to the cervical spine, lumbar spine, and both shoulders were caused by the subject motor accident (the MAC). The MAC is now subject to review by this Panel under s 7.26 of the MAI Act, following an application by the insurer. The President's delegate determined that there was reasonable cause to suspect that the certificate was incorrect in a material respect. 5. This review proceeds by way of a new assessment of all matters with which the prior certificate was concerned, in accordance with s 7.26(5) of the MAI Act. The Review Panel comprises a legally qualified Member and two Medical Assessors. The Panel has reviewed the joint bundle of documents, including submissions, treating and expert medical reports, imaging, and contemporaneous clinical records. Mr Dragicevic was not re-examined by the on the review. 6. The parties were invited by the Panel to make submissions on the necessity of a further medical examination of the claimant. The claimant submitted that a fresh examination was not warranted, and that the matter was capable of being determined "on the papers" on the basis of the existing medical evidence, including contemporaneous imaging and the clinical assessment undertaken by the Medical Assessor. The claimant contended that there were no identified deficiencies in the original examination and that the radiological evidence overwhelmingly supported the diagnosis and causation of the injuries in dispute. The insurer, by contrast, submitted that a re-examination was appropriate, contending that the nature of the claimant's alleged injuries was inconsistent with the relatively minor mechanics of the collision. It relied on the biomechanical report of Dr McIntosh and the clinical opinion of

Dr Mitchell in support of its position that the forces involved were insufficient to cause a cervical spine fracture, and submitted that the Medical Assessor had failed to provide adequate reasons for concluding that the accident caused that injury. 7. The Panel determined that a further medical examination was not necessary in this matter. The medical assessment under review was conducted relatively recently and included a detailed clinical examination by the Medical Assessor, the adequacy of which was not challenged on any specific procedural or substantive ground. The claimant's presentation has been extensively documented in the contemporaneous treating records, radiological imaging, and multiple expert reports. The issues in dispute, namely, causation and the interpretation of radiological and biomechanical evidence, are not matters that turn on direct physical observation but rather on the proper evaluation of existing material. The Panel was satisfied that the available evidence was sufficiently comprehensive, consistent, and current to permit a proper re-assessment of the claimant's injuries without the need for further clinical examination. There was no suggestion that the claimant's condition had materially changed since the date of the original assessment, and the Panel was satisfied that the available evidence was sufficiently complete and reliable to allow a proper reconsideration of all matters without the need for re-examination pursuant to rule 128(2) of the Personal Injury Commission Rules 2021.

1. The MAC recorded an assessment of the claimant's degree of permanent impairment in accordance with the Act and the Motor Accident Guidelines (the Guidelines). Following a clinical examination conducted on 8 January 2025, the Medical Assessor concluded that the following injuries were caused by the subject motor accident:

(a) cervical spine - C6 spinous process fracture;

(b) lumbar spine - soft tissue injury;

(c) left shoulder - soft tissue injury; and

(d) right shoulder - soft tissue injury.

1. The Medical Assessor assessed WPI in respect of those injuries at 11%, exceeding the threshold in s 4.11 of the MAI Act.
2. The Medical Assessor recorded that the claimant, a formwork carpenter, was injured when his stationary vehicle was struck from behind by another vehicle while he was restrained by a seatbelt. He reported immediate neck and bilateral shoulder pain (more severe on the left), together with lower back pain and paraesthesia affecting his limbs. He attended Liverpool Hospital later that evening, where CT imaging confirmed a fracture of the C6 spinous process.
3. The Medical Assessor took a detailed history of treatment. Following discharge from hospital, the claimant was referred to Dr Habib, who recorded signs consistent with cervical discopathy and a suspected SLAP tear of the left shoulder. Subsequent MRI imaging confirmed left-sided labral tearing, subacromial bursitis, and supraspinatus tendinosis. The claimant was also referred to Dr Guirgis, who diagnosed post-traumatic mechanical derangement of the cervical and lumbar spine and bilateral shoulder impingement syndromes. Later review by Professor Murrell confirmed structural shoulder pathology and recommended arthroscopic stabilisation, although surgery did not proceed. Treatment included analgesic medication, physiotherapy, hydrotherapy, CT-guided cervical injection, psychiatric care, and use of Ajovy injections for headache management. The Medical Assessor noted that at the time of assessment, the claimant continued to report persistent symptoms in the neck, lower back and left shoulder.
4. On examination, the Medical Assessor observed restriction of cervical spine motion to one-third of normal in all directions, midline tenderness, and voluntary muscle guarding. There were non-verifiable complaints of bilateral upper limb numbness. Neurological examination of the upper limbs was unremarkable, with normal reflexes and no motor or sensory deficit. The lumbar spine was tender with range of motion restricted to half of normal. Straight leg raise was to 70 degrees bilaterally without root tension signs. Neurological examination of the lower limbs was similarly within normal limits.
5. With respect to the shoulders, the Medical Assessor identified bilateral acromioclavicular joint tenderness. Active range of motion was symmetric (flexion to 140°, abduction to 130°, internal and external rotation to 60°), but the movements were affected by voluntary guarding. He found that range of motion was unsuitable for impairment assessment. He noted that MRI imaging demonstrated moderate AC joint arthropathy and subacromial bursitis bilaterally, with additional SLAP pathology in the left shoulder.
6. Applying the American Medical Association Guides to the Evaluation of Permanent Impairment (Fourth Edition) (the Guides) and the Guidelines, the Medical Assessor assessed:

(a) cervical spine: 5% WPI (DRE category II - spinous process fracture with non-verifiable radicular complaints);

(b) lumbar spine: 0% WPI (DRE category I - no objective clinical signs of radiculopathy);

(c) left shoulder: 3% WPI (based on AC joint arthropathy with synovial hypertrophy), and

(d) right shoulder: 3% WPI (on the same basis as the left).

1. The combined WPI was assessed at 11%. The Medical Assessor did not apply any deduction for pre-existing impairment. While acknowledging imaging evidence of degenerative changes in the spine and shoulders, he observed that there was no documented history of symptoms prior to the accident. He found that any aggravation of degenerative pathology had resolved within 12 months of the injury and that the residual impairment was attributable to the accident.
2. The Medical Assessor concluded that the claimant's injuries had stabilised and were unlikely to change by more than 3% WPI in the next 12 months. He certified that the claimant sustained a total permanent impairment of 11% as a result of the subject motor accident.

1. The certificate of the Medical Assessor dated 15 January 2025 was the subject of an application for review under s 7.26 of the Act. The application was made by the insurer.
2. In its submissions dated 10 February 2025, the insurer contended that the Medical Assessor's certificate was incorrect in a material respect. It submitted that the Medical Assessor failed to apply an appropriate deduction in respect of pre-existing degenerative changes affecting the cervical spine, lumbar spine and both shoulders. The insurer relied on imaging studies and medico-legal reports obtained prior to the assessment, including the reports of Dr Robin Mitchell and Dr Andrew McIntosh, both of whom had expressed the view that the claimant's presentation reflected underlying degenerative pathology not caused by the subject motor accident. Dr Mitchell had specifically attributed the cervical and lumbar spine findings to pre-accident changes and assessed no permanent impairment in those regions. The insurer argued that, having accepted that degenerative pathology was present, the Medical Assessor was required to consider whether a deduction under cl 6.18 of the Guidelines was warranted, and erred in failing to do so.
3. The claimant opposed the application by submissions dated 3 March 2025. It was submitted on behalf of the claimant that the Medical Assessor had correctly applied the criteria for assessing WPI under the Guides and the Guidelines. The claimant relied on the reports of

Dr Medhat Guirgis and Dr James Bodel, both of whom diagnosed post-traumatic injury to the cervical spine, lumbar spine and shoulders, and who found that the clinical presentation was consistent with the mechanism of injury described. The claimant submitted that the mere presence of age-appropriate degenerative change on imaging did not require a deduction, and that in circumstances where the assessor was satisfied the injuries were caused by the accident and had stabilised, the WPI assessment of 11% was open on the evidence. 4. By written determination dated 13 March 2025, the President's delegate determined that there was reasonable cause to suspect that the certificate of the Medical Assessor was incorrect in a material respect. The delegate noted that the Medical Assessor had accepted that there was evidence of pre-existing degenerative change in each of the relevant regions, but had neither applied a deduction under cl 6.18 of the Guidelines nor provided adequate reasoning for not doing so. The delegate concluded that this gave rise to a material question as to the correctness of the assessment, particularly given the divergent expert views on causation and the extent of injury. On that basis, the matter was referred for review by a Medical Review Panel in accordance with s 7.26(5) of the Act.

1. Clause 14F of Schedule 1 to the Personal Injury Commission Act 2020 (NSW) (the PIC Act) provides that the review provisions introduced by the Act apply to decisions of a "new decision-maker", as defined in cl 14A(1) of Schedule 1. As the certificate of the Medical Assessor in this matter was issued on 15 January 2025, the new review provisions apply.
2. Pursuant to those provisions, a review is conducted by a Review Panel comprising two Medical Assessors and a Member assigned to the Motor Accidents Division of the Commission. In accordance with that procedure, the President's delegate referred the matter for determination by this Panel, as presently constituted.
3. Part 5 of the PIC Act empowers the Commission to make rules governing the practice and procedure of proceedings before it, including proceedings before a Review Panel. Rules 127 to 130 of the Personal Injury Commission Rules 2021 are made under that authority and apply to this proceeding.
4. The Review Panel is empowered to determine the manner in which it conducts the review, and may elect to proceed on the papers or to re-examine the claimant. In this matter, the Panel determined that a re-examination was appropriate and directed the parties to produce a joint bundle of all relevant material in support of their respective positions.
5. A review under s 7.26 of the MAI Act is by way of a new assessment of all matters with which the original medical assessment was concerned. Section 7.25 of the Act provides that the Panel may adopt any agreement reached between the parties as to the degree of permanent impairment or the causation of a particular injury, without requiring that those matters be formally re-assessed.
6. The injuries referred to the Panel for review in this matter are as follows:

(a) in relation to the cervical spine, musculo-ligamentous strain or sprain, with C6-7 disc involvement, including a central posterior disc protrusion and a left para-foraminal disc protrusion at that level, associated with left C6-7 brachialgia and headaches;

(b) in relation to the lumbar spine, post-mechanical derangement, comprising musculo-ligamentous sprain or strain with intervertebral disc involvement, including a central posterior disc protrusion contacting the S1 nerve roots, and a right centro-oblique posterior discophytic protrusion encroaching upon the right L4/5 nerve root exit, with associated L5/S1 radiation and features of lumbosacral radiculopathy;

(c) in relation to the left shoulder, subacromial impingement with contusion of the articular surfaces, spraining of the supporting capsular and ligamentous structures, compression of the subacromial bursa, partial thickness insertional supraspinatus tendon tear, posterior superior labral tear with a multiloculated paralabral cyst, and subacromial/subdeltoid bursitis, and

(d) in relation to the right shoulder, subacromial impingement with contusion of the articular surfaces, spraining of the supporting capsular and ligamentous structures, compression of the subacromial bursa, SLAP tear of the biceps anchor, supraspinatus and infraspinatus tendinosis, and subacromial/subdeltoid bursitis.

1. The Panel issued procedural directions requiring the parties to file a joint bundle of material to be relied upon on the review. That direction was complied with. The Panel has reviewed the material in the joint bundle and briefly sets out its consideration of the evidence.

Liverpool Hospital - Emergency Department records (24 October 2021)

1. The claimant attended Liverpool Hospital Emergency Department on the evening of the motor accident. He was triaged at approximately 6.51pm and discharged in the early hours of 25 October 2021. The clinical notes record that the claimant was the restrained driver of a vehicle struck from the rear while stationary. He complained of posterior neck pain and bilateral shoulder discomfort, with no reported loss of consciousness. Neurological examination was normal. A CT scan of the cervical spine revealed an undisplaced fracture of the C6 spinous process. There was no evidence of spinal cord compression or dislocation. Analgesia was administered, no cervical collar was applied and the claimant was discharged with advice for conservative management.

Dr Sheikh M Habib - report dated 29 October 2021

1. Dr Sheikh M Habib, orthopaedic surgeon, reviewed the claimant five days following the accident, on referral from the claimant's general practitioner. The report records that the claimant continued to experience pain radiating from the neck to both shoulders, accompanied by paraesthesia affecting the ulnar distribution of the hands, more prominent on the left. Dr Habib noted pain and stiffness in the left shoulder and milder symptoms in the right. Clinical examination revealed marked muscular spasm of the cervical paraspinal musculature and tenderness over the C6 spinous process, with restriction of movement in flexion, extension, and rotation. The left shoulder exhibited restricted motion and pain on external rotation and abduction.
2. Dr Habib opined that the claimant had sustained injuries to the cervical spine in a sudden extension-flexion mechanism consistent with a rear-end collision, together with a jarring trauma to the left shoulder, likely from seatbelt restraint. He referred the claimant for MRI imaging of the cervical spine and left shoulder to further evaluate the suspected discopathy and rotator cuff pathology.

MRI cervical spine and left shoulder - 30 October 2021

1. Dr Ganeshan reported on MRI studies of the cervical spine and left shoulder performed six days post-accident. In respect of the cervical spine, the imaging demonstrated a disc bulge at the C6/7 level without evidence of spinal cord or nerve root compression. In addition, there was foraminal narrowing at the C4/5 level on the right, with the potential for right C5 nerve root impingement.
2. The MRI of the left shoulder revealed acromioclavicular joint arthropathy characterised by effusion, synovitis, and associated bone oedema. There was also evidence of subacromial and subdeltoid bursitis, a SLAP tear involving the biceps anchor, and mild supraspinatus and infraspinatus tendinosis. These findings were consistent with the clinical impression of post-traumatic structural injury to the left shoulder, and corroborated the history of left-sided shoulder pain and restriction following seatbelt-related trauma during the subject accident.

1. Dr Mayat reported on MRI scans of the lumbar spine and right shoulder conducted five weeks after the subject accident. The lumbar spine images disclosed degenerative spondylitic changes at the L3/4 and L4/5 levels, with a broad-based disc bulge at L3/4 causing impingement on the exiting L3 nerve root. At L4/5, a further broad-based disc bulge was observed, encroaching upon the central spinal canal and producing foraminal narrowing more marked on the right, though without definite neural compression. At L5/S1, there was a broad-based disc bulge contacting the S1 nerve roots in the lateral recesses of the canal.
2. MRI imaging of the right shoulder revealed a posterior superior labral tear accompanied by a prominent multiloculated paralabral cyst. Additional findings included subacromial and subdeltoid bursitis, a partial-thickness insertional tear of the supraspinatus tendon, and acromioclavicular joint arthropathy.
3. Taken together, these findings supported the presence of bilateral shoulder pathology and multilevel lumbar disc disease. While the radiological features included degenerative components, they were consistent with traumatic aggravation in the context of the claimant's presentation and temporal onset of symptoms following the motor accident.

Dr Sheikh M Habib - letter dated 10 December 2021

1. Dr Habib reviewed the claimant following CT-guided left C6/7 perineural steroid injection. The claimant reported only minor symptomatic benefit. Examination findings remained consistent with ongoing radicular pain and mechanical restriction in the cervical spine. The left shoulder continued to demonstrate subacromial impingement and SLAP-type pathology. Dr Habib considered the claimant's condition stable and continued to recommend non-surgical management with analgesia and physiotherapy. He did not support surgical intervention at that stage.

Dr Predrag Tomasevic - letter to Dr Borire dated 7 December 2021

1. The claimant's general practitioner, Dr Tomasevic, provided a referral to neurologist

Dr Adeniyi Borire, seeking clarification regarding the persistent sensory symptoms in the claimant's upper and lower limbs. The referral summarised the diagnostic findings to date, including the C6 spinous process fracture and MRI-confirmed shoulder and spinal pathology. Dr Tomasevic noted the claimant's ongoing complaints of paraesthesia, neuropathic pain, and cervical instability.

Dr Adeniyi Borire - clinical notes dated 5 January 2022 and 30 March 2022

1. Dr Borire, neurologist, reviewed the claimant in early 2022 following referral by the general practitioner. The initial consultation on 5 January 2022 was in relation to the claimant's ongoing paraesthesia and cervicogenic headache. A neurological examination was performed and nerve conduction studies were recommended. Clinical notes from

30 March 2022 record follow-up after those investigations, with no evidence of upper limb radiculopathy. MRI and MRA of the brain and cervical spine excluded central neurological causes for the claimant's symptoms. Dr Borire noted features consistent with chronic cervical pain syndrome but did not identify evidence of a primary neurological disorder.

Dr Medhat Guirgis - report dated 1 February 2022

1. Dr Guirgis, orthopaedic surgeon, reviewed the claimant and provided a comprehensive medicolegal opinion. Based on clinical assessment and review of imaging, he diagnosed:

(a) post-traumatic mechanical derangement of the cervical spine;

(b) post-traumatic mechanical derangement of the lumbar spine;

(c) post-traumatic symptoms of subacromial impingement with labral tear in the right shoulder, and

(d) post-traumatic symptoms of subacromial impingement with SLAP tear in the left shoulder.

1. Dr Guirgis opined that the injuries were causally related to the subject accident and that the claimant's symptomatology was consistent with a flexion-extension mechanism and seatbelt-related shoulder trauma. He noted an absence of pre-accident complaints in the relevant anatomical areas and considered the claimant to be suffering from a complex and painful post-traumatic musculoskeletal condition. He referred the claimant for nerve conduction studies with Associate Professor Raymon Schwartz and suggested that ongoing orthopaedic and pain management care would be required.

Associate Professor Raymon Schwartz - report dated 11 March 2022

1. Associate Professor Schwartz conducted nerve conduction studies and electromyography (EMG) at the request of Dr Guirgis. The upper limb studies were normal. Lower limb studies revealed a mild right L5 radiculopathy. However, A/Prof Schwartz opined that the finding was likely incidental and did not explain the claimant's primary presentation. No surgical intervention was recommended. Conservative management with physical therapy and pain modulation was advised.

Professor George Murrell - report dated 2 May 2022

1. Professor Murrell, an orthopaedic shoulder specialist, was consulted regarding the claimant's persistent left shoulder symptoms. He confirmed MRI findings of a posterior superior labral tear, a paralabral cyst, and supraspinatus tendon involvement. On examination, the claimant exhibited good range of motion and a positive O'Brien's sign. Arthroscopic stabilisation was recommended to address labral pathology. The claimant declined surgical intervention due to the insurer's refusal to fund the procedure.

Dr Medhat Guirgis - report dated 29 October 2022

1. In a further report, Dr Guirgis conducted a formal assessment of WPI. He assessed the claimant as having 21% WPI, apportioned as follows:

(a) cervical spine - 5% WPI (with a 0.5% deduction for pre-existing degenerative change);

(b) lumbar spine - 5% WPI (with a 0.5% deduction);

(c) left upper extremity - 7% WPI (with a 0.8% deduction), and

(d) right upper extremity - 6% WPI (with a 0.7% deduction).

1. Dr Guirgis reiterated that the claimant's condition was attributable to the subject motor accident and had reached maximal medical improvement. He noted that, while radiological evidence disclosed underlying degenerative changes, these had been asymptomatic prior to the accident and had been aggravated by the incident.

Dr Blagoje Kuljic - reports dated 25 October 2022 and 28 May 2023

1. Dr Kuljic, a treating orthopaedic physician, reviewed the claimant on multiple occasions. In reports dated 25 October 2022 and 28 May 2023, he confirmed the persistence of bilateral shoulder pain and cervical and lumbar spine symptoms. He diagnosed mechanical cervical and lumbar spine injury, right-sided L5/S1 radiculopathy, and bilateral shoulder impingement syndromes with partial tearing. Conservative management with analgesia and physical therapy was recommended. Dr Kuljic did not support surgical intervention at the time of reporting but noted ongoing functional restriction.

Dr Robin Mitchell - reports dated 5 September 2022 and 14 October 2022

1. Dr Robin Mitchell, occupational physician, conducted a medicolegal assessment of the claimant on behalf of the insurer. In his primary report dated 5 September 2022, Dr Mitchell concluded that the claimant's physical presentation was largely inconsistent and exaggerated. He noted extensive voluntary muscle guarding and a lack of objective clinical signs. Range of motion in the shoulders was recorded as so inconsistent that it was deemed "meaningless" for impairment assessment purposes.
2. Dr Mitchell accepted that the claimant had sustained soft tissue injuries in the subject motor accident but opined that the cervical spine fracture, though radiologically confirmed, was of minor significance and had not resulted in neurological compromise. He further considered the lumbar spine and shoulder pathology to reflect pre-existing, moderate degenerative changes. He assessed WPI as follows:

(a) cervical spine - 0% WPI;

(b) lumbar spine - 0% WPI;

(c) right shoulder - 2% WPI (based on acromioclavicular joint degeneration), and

(d) left shoulder - 3% WPI (same basis)

1. In his supplementary report dated 14 October 2022, Dr Mitchell reiterated his opinion that the motor accident had resulted in minor, temporary aggravation of pre-existing pathology, which ought to have resolved within 12 months. He attributed the claimant's ongoing symptoms to non-compensable degenerative conditions.

Dr Andrew McIntosh - biomechanical analysis dated 5 April 2022

1. Dr Andrew McIntosh, biomechanical engineer, was retained by the insurer to provide an expert opinion in relation to the biomechanical forces generated in the subject motor vehicle accident and their capacity to cause the injuries alleged by the claimant. In preparing his report, Dr McIntosh reviewed photographs of the claimant's vehicle, details of the collision configuration, and available medical reports and imaging.
2. Dr McIntosh described the accident as involving a low-speed rear-end collision, with minimal property damage to either vehicle. He noted that the claimant's vehicle was fitted with a towbar, which he opined would have further absorbed and dispersed the energy of the impact. He stated that, in his view, the degree of vehicle deformation was minor and insufficient to generate biomechanical forces capable of causing fracture of the cervical spine, or structural injury to the lumbar spine or shoulders.
3. He concluded that the collision was biomechanically comparable to "low-severity exposures" encountered in everyday settings and unlikely to result in musculoskeletal trauma. He expressed the opinion that the C6 spinous process fracture was not plausibly attributable to the accident, and that the imaging findings of disc pathology and bilateral shoulder abnormalities were more consistent with degenerative changes than with trauma. He further noted that the bilateral symmetry of the shoulder findings supported a non-traumatic origin.
4. Dr McIntosh did not accept that the subject collision involved sufficient acceleration, force transmission or body kinematics to result in spinal, shoulder or soft tissue injury. He stated that, based on known thresholds for tissue injury in rear-end collisions and the absence of significant vehicle deformation, the claimant's injuries were unlikely to have been caused by the incident described.

1. Dr James Bodel, orthopaedic surgeon, provided an independent opinion at the request of the claimant's solicitors. He diagnosed traumatic injury to the cervical and lumbar spine, with persistent impairment of the left shoulder, and agreed that the subject accident had caused a significant and enduring exacerbation of musculoskeletal symptoms. Dr Bodel considered that the mechanism of injury - rear-end collision with sudden deceleration - was consistent with the injuries reported and substantiated by imaging and early medical records.
2. He assessed permanent impairment as follows:

(a) cervical spine - 5% WPI;

(b) lumbar spine - 5% WPI;

(c) left shoulder - 6% WPI (on range of motion impairment), and

(d) right shoulder - 0% WPI (normal ROM at time of assessment)

1. Dr Bodel concluded that the claimant had reached maximum medical improvement, and that his current level of impairment was unlikely to change in the future.

Grant Johnston - report dated 17 July 2024 and letter dated 8 August 2024

1. Mr Grant Johnston, consulting engineer, was retained to provide an expert opinion concerning the collision dynamics and biomechanical plausibility of injury sustained by the claimant in the motor vehicle accident of 24 October 2021. His opinion was informed by the insurer's investigation materials, photographs of the involved vehicles, a review of the claimant's medical evidence, and application of biomechanical principles.
2. Mr Johnston accepted that the claimant's vehicle was stationary at the time of impact, and that it was struck from behind by another vehicle fitted with a bull bar. He observed that, while the rearward deformation of the claimant's vehicle was minimal, that fact alone was not determinative of the forces transmitted to the occupant. He noted that modern vehicles are designed to minimise structural deformation at low to moderate speeds, and that energy transfer to occupants may still occur without visible external damage.
3. Mr Johnston observed that the presence of a towbar or similar reinforcement could have contributed to the efficient transmission of force into the occupant cabin, particularly in the context of a rigid frontal structure (such as a bull bar) on the impacting vehicle. He noted that occupant acceleration in rear-end impacts can occur independently of gross crush damage, and that the claimant's seated posture, seatbelt restraint and head positioning at the time of impact may have produced axial loading sufficient to result in musculoskeletal injury.
4. Mr Johnston further considered the claimant's age and physical condition to be relevant factors. He stated that individuals with underlying but asymptomatic spinal degeneration may be more susceptible to injury at lower thresholds. He considered that the biomechanical scenario described was not incompatible with the claimant sustaining a C6 spinous process fracture, cervical and lumbar disc injuries, and shoulder pathology, and that such injuries could be plausibly explained by the mechanism of a rear-end collision under the circumstances described.
5. In his supplementary letter dated 8 August 2024, Mr Johnston reiterated his view that injury cannot be excluded solely on the basis of low property damage, and that the mechanism of the accident was consistent with the claimant's reported injuries.

Certificates of Capacity - Dr Predrag Tomasevic (Various Dates from 9 November 2021)

1. A series of certificates of capacity were issued by the claimant's treating general practitioner, Dr Predrag Tomasevic, beginning on 9 November 2021. Each certificate diagnosed the claimant with multiple injuries causally linked to the motor accident on 24 October 2021. These included:

(a) a confirmed C6 spinous process fracture (via CT imaging);

(b) soft tissue injuries to the cervical spine;

(c) bilateral shoulder injuries;

(d) lumbar spine involvement, and

(e) widespread nerve root irritation affecting the upper and lower limbs.

1. In the initial certificate dated 9 November 2021, Dr Tomasevic noted that the claimant's injuries were entirely consistent with the described mechanism of injury and confirmed the absence of any relevant pre-existing pathology. The claimant was noted to have no current work capacity, with limited tolerance for sitting (30 minutes), standing (15 minutes), and lifting (5 kg). Work restrictions included avoidance of pushing, pulling, bending, and driving. The management plan included continued analgesia, review by an orthopaedic surgeon (Dr S Habib), and psychological support due to symptoms of anxiety and insomnia.
2. Subsequent certificates dated 23 November 2021, 8 December 2021, and 22 February 2022 reiterated the same diagnostic profile and functional limitations. Each certificate reaffirmed the clinical stability of the C6 fracture and documented persistent cervical, lumbar and bilateral shoulder symptoms. The claimant remained certified as having no current work capacity, with ongoing referral to specialist care and physiotherapy.
3. Dr Tomasevic's clinical records and correspondence consistently supported a diagnosis of post-traumatic musculoskeletal injury involving the cervical and lumbar spine and both shoulders, with objective radiological and specialist corroboration. No alternative cause was identified in the treating materials.

General practitioner records - pre-accident history

1. The general practitioner records of the claimant for the period preceding the motor vehicle extending from October 2019 to the date of accident. They disclose treatment for a range of general health concerns, but contain no evidence of any complaint, investigation, or treatment referable to the cervical spine, lumbar spine, or shoulders prior to the subject accident.
2. The claimant attended his general practitioners during this period for routine medical issues. On 15 October 2020, there is a record of consultation for left hip pain, with a diagnosis of osteoarthritis, and subsequent imaging and orthopaedic referral. There are also references to occasional musculoskeletal complaints in the lower limbs (such as lateral epicondylitis and left toe subluxation).
3. However, the records contain no reference to neck pain, lower back pain, radiculopathy, or any limitation of movement or function involving the cervical or lumbar spine, nor any reference to shoulder pain, shoulder instability, rotator cuff symptoms, or subacromial pathology prior to the accident. At no time during the relevant period is there any complaint suggestive of pre-existing injury or impairment in the anatomical regions now in dispute.
4. The absence of such complaints is particularly notable given the frequency of medical consultations and the claimant's occupation as a formwork carpenter, which would reasonably be expected to prompt presentation had such conditions been symptomatic.

General practitioner records - Dr Predrag Tomasevic (Various Dates 2021-2022)

1. The clinical records of Dr Tomasevic, the claimant's treating general practitioner, document an uninterrupted course of care following the motor accident. Dr Tomasevic's notes from late October 2021 onward corroborate early hospital findings of a C6 spinous process fracture, with associated neck pain, paraesthesia, and bilateral shoulder discomfort. Repeated entries record complaints of upper limb numbness, limited range of motion in both shoulders, and mechanical lumbar back pain.
2. Dr Tomasevic consistently maintained that the claimant's presentation was consistent with traumatic soft tissue injury, with complicating features including nerve root irritation and sleep disturbance. Referrals were made to orthopaedic, neurological, and radiological specialists, including Dr Habib, Dr Borire, Dr Guirgis, and Prof Murrell. Dr Tomasevic also managed the claimant's pharmacological regimen, which included analgesics, anti-inflammatories, sedatives (for insomnia), and psychiatric medications for mood disturbance arising secondary to pain.
3. The records do not indicate any relevant pre-accident complaints in the affected anatomical regions, and the treating general practitioner expressed repeated concern about the claimant's functional decline and poor prognosis without specialist-supported intervention.

Aspire Physiotherapy - physiotherapy records (Late 2021-Early 2022)

1. Physiotherapy treatment was provided at Aspire Physiotherapy and Sports Injury Clinic. The treatment records identify a programme of post-accident rehabilitation involving manual therapy and supervised exercise focused on the cervical spine, shoulders, and lumbar region. The notes recorded limited response to treatment, with persistent stiffness and pain, particularly affecting the claimant's ability to lift, bend, and rotate his neck or shoulders.
2. The treating physiotherapist noted reduced shoulder range of motion, ongoing supraspinatus tenderness, scapular dysfunction, and impaired core stability. Reports highlighted significant compensatory movement and pain on resisted motion in the left shoulder, with functional restrictions consistent with the injuries diagnosed by the treating orthopaedic specialists. The claimant underwent over 40 sessions of therapy. The physiotherapist ultimately reported that the claimant had reached a plateau in recovery and referred him back for surgical and/or pain management review.

Southwest Neurology - Dr Adeniyi Borire (30 March 2022)

1. Dr Borire, neurologist, reported that he had reviewed the claimant in relation to symptoms of chronic headache, neck pain, and bilateral shoulder discomfort with paraesthesia. While he found no objective electrophysiological or radiological evidence of a primary neurological disorder, he accepted that the claimant's presentation was consistent with post-traumatic cervical radicular irritation and mechanical impingement. He did not support surgical decompression but encouraged conservative management, including targeted pain control, physical therapy, and review of nerve root function over time.

1. The claimant submitted that the Medical Assessor's conclusions on both causation and permanent impairment were open on the evidence and should not be disturbed. It was submitted that the C6 spinous process fracture was diagnosed on the day of the accident and that there was no evidence of any prior trauma, complaint or treatment referable to the cervical spine. The claimant referred to consistent clinical findings across the treating records, the early onset of symptoms, and the imaging findings which confirmed an acute fracture. The claimant submitted that the opinions of Dr Guirgis and Dr Bodel supported the attribution of the injury to the accident, and that the insurer's reliance on biomechanical analysis and degeneration was misplaced in circumstances where the clinical picture was clear. In respect of the shoulders and lumbar spine, the claimant submitted that the impairments had also been appropriately assessed and attributed, and that there was no objective evidence of pre-existing symptomatic impairment. The claimant accordingly submitted that no deduction was required or permitted under cl 6.31 of the Guidelines.
2. The insurer submitted that the Medical Assessor erred in attributing causation for the C6 spinous process fracture to the subject motor accident. It maintained that the forces involved in the accident were insufficient to cause such a fracture, citing the opinion of Dr McIntosh, who described the collision as biomechanically incapable of producing structural injury. The insurer also relied on the reports of Dr Mitchell, who attributed the claimant's presentation to degenerative conditions and assessed no impairment in the cervical or lumbar spine. The insurer submitted that the Medical Assessor failed to explain how the fracture could be linked to the accident given the absence of radiological indicators of acute trauma beyond the spinous process fracture, and further failed to apply any deduction for degenerative changes that were said to have pre-dated the accident.

1. The Panel has considered whether there is any medical evidence establishing that the claimant received treatment for, or experienced symptoms referable to, the cervical spine, lumbar spine, or shoulders prior to the motor vehicle accident on 24 October 2021.
2. The Panel finds that there is no contemporaneous or probative medical evidence demonstrating that the claimant was treated for, or complained of, any condition affecting the cervical spine, lumbar spine, or either shoulder prior to the subject accident. The claimant's general practitioner records, extending from October 2019 to the date of accident, disclose treatment for a range of general health concerns, but contain no evidence of any complaint, investigation, or treatment referable to the cervical spine, lumbar spine, or shoulders prior to the subject accident. The emergency department records from Liverpool Hospital dated

24 October 2021 do not record any relevant past medical history at the time of presentation. The treating general practitioner, Dr Tomasevic, who commenced care shortly after the accident and completed multiple certificates of capacity, consistently recorded "nil" pre-existing conditions referable to the areas now in dispute. 3. This position is further supported by the history taken by the Medical Assessor, who noted that the claimant denied any previous injuries or claims, and stated that he had been in good general health prior to the accident. That account was accepted by the Medical Assessor and is consistent with the treating records. The claimant's occupational history likewise supports the inference that he was physically functional and asymptomatic in the relevant anatomical regions prior to the subject accident, having worked full-time in a physically demanding role as a formwork carpenter. 4. The Panel is aware that the insurer referred to a prior workers compensation claim and Total and Permanent Disability application. However, the documentary material identifies those matters as relating to other anatomical regions, including a knee injury and unrelated systemic conditions. There is no evidence that any of the conditions identified affected the cervical spine, lumbar spine, or shoulders, nor that they resulted in any impairment of function prior to the motor vehicle accident. No clinical record before the Panel documents any prior diagnosis, treatment, or restriction referable to the areas now under review. 5. Accordingly, the Panel finds that there is no evidence of prior symptomatic impairment in the cervical spine, lumbar spine, or shoulders. While imaging following the subject motor accident discloses features of degenerative change, there is no basis to infer that such changes were functionally relevant or symptomatic prior to the subject motor accident.

1. The Panel convened for a case conference on 29 July 2025 to consider the outstanding issues of causation, the weight to be afforded to competing expert evidence, and the clinical plausibility of the cervical spine injury in particular.
2. The fracture of the C6 spinous process was identified radiologically on the day of the subject motor accident. The Panel discussed the biomechanics of such an injury and was satisfied that it is typically associated with a flexion-extension mechanism causing traction through the interspinous ligaments. The Panel accepted that such a mechanism is plausible in a rear-end collision involving a seatbelt-restrained occupant and that it is not dependent on external indicators of vehicle damage.
3. The Panel was not persuaded that the presence of age-related degenerative changes rendered the claimant predisposed to fracture of the spinous process. The spinous process, unlike trabecular bone, is not commonly affected by osteoporotic weakening, and the suggestion that degenerative disc disease or facet arthropathy could produce spontaneous fracture in the absence of trauma was rejected as unsupported by clinical experience.
4. The Panel placed weight on the temporal relationship between the subject motor accident and the onset of symptoms, the absence of prior complaint, and the immediate identification of the fracture on imaging. There was no competing explanation for the fracture, and the Panel was satisfied that it was more likely than not sustained in the course of whiplash mechanism of the subject motor accident.
5. Although the insurer had described the collision as minor, the Panel noted that the claimant's vehicle was struck by a vehicle fitted with a bull bar, that police and ambulance services were called to the scene, and that the claimant was transported to hospital. These facts, in the Panel's view, supported the inference that the collision was of sufficient magnitude to cause injury. The issue for the Panel was not the perceived "seriousness" of the subject motor accident, but whether the mechanism of injury was consistent with the injury sustained. On that question, the Panel was satisfied that causation was established on the balance of probabilities.
6. The Panel also considered the opinion of Dr McIntosh, biomechanical engineer, who was retained by the insurer to assess whether the forces involved in the subject accident were capable of causing the injuries reported by the claimant, particularly the C6 spinous process fracture. While acknowledging Dr McIntosh's expertise in the field of applied biomechanics, the Panel found his opinion unpersuasive for several reasons.
7. First, the Panel observed that Dr McIntosh's reasoning proceeded from a generalised biomechanical model that assumed a direct and quantifiable correlation between visible vehicle deformation and likelihood of injury. His report focused on the absence of significant crush damage to the claimant's vehicle and posited that, as a result, the magnitude of force transmitted to the occupant must have been insufficient to result in structural injury. However, this premise fails to account for established clinical knowledge that soft tissue and even osseous injuries can occur in low-speed rear-end collisions, particularly where the impacting vehicle is fitted with a rigid frontal structure such as a bull bar, as was the case here, and where a towbar or stiffened frame increases energy transmission into the cabin.
8. Second, Dr McIntosh's analysis did not meaningfully engage with the claimant's individual characteristics, such as age, seating posture, the presence of a seatbelt restraint, or any underlying spinal changes that may have rendered him more susceptible to injury in the particular circumstances of the collision. His opinion applied a population-level biomechanical threshold without accounting for the variability in human tolerance or the documented medical history of this claimant.
9. Third, the Panel noted that Dr McIntosh did not address, and did not appear to be qualified to address, the specific clinical sequence in this case, namely, the immediate onset of posterior neck pain following the accident, the contemporaneous CT diagnosis of a C6 spinous process fracture at Liverpool Hospital on the same day, and the complete absence of any prior cervical complaints or trauma. His conclusion that the injury was likely degenerative in origin was not based on any imaging showing signs of chronicity (such as sclerosis, remodelling, or bony resorption) and was inconsistent with the acute traumatic features recorded on imaging and in clinical examination.
10. Further, the Panel considered that Dr McIntosh did not explain how a person with a pre-existing fracture of the spinous process would be capable of continuing in physically demanding employment, as the claimant had done, with no reported symptoms, no treatment, and no indication of limitation. The suggestion that such a fracture could have pre-dated the subject motor accident but remained entirely asymptomatic until the incident in question lacked clinical plausibility and was unsupported by any treating or radiological evidence.
11. In light of these factors, the Panel concluded that Dr McIntosh's opinion rested on a series of abstract biomechanical assumptions that were disconnected from the claimant's documented injury profile, mechanism of trauma, and post-accident course. His report did not displace the clear temporal and clinical link between the accident and the injury sustained, and the Panel accordingly gave his opinion little weight.

1. The Panel has considered whether any deduction should be applied under cl 6.31 of the Guidelines in respect of alleged pre-existing impairment affecting the cervical spine, lumbar spine, or shoulders.
2. Radiological imaging conducted after the subject motor accident disclosed features of degeneration in each of the relevant anatomical regions. An MRI of the cervical spine dated 30 October 2021 demonstrated a C6/7disc bulge and foraminal narrowing at C4/5. MRI of the lumbar spine dated 30 November 2021 revealed disc protrusions at L4/5 and L5/S1, with contact of the S1 nerve roots and bilateral facet arthropathy. Imaging of the shoulders identified AC joint arthropathy, supraspinatus tendinosis, and SLAP-type tears in both shoulders.
3. These findings were relied upon by Dr Mitchell and Dr McIntosh, both retained by the insurer, in support of the contention that the claimant's presentation reflected longstanding degenerative changes unrelated to trauma. In particular, Dr McIntosh expressed the view that the collision lacked sufficient force to cause structural injury, and Dr Mitchell attributed the entirety of the claimant's impairment to age-related degeneration.
4. However, the Panel notes that the Guidelines draw a distinction between radiological evidence of degeneration and pre-existing impairment. Clause 6.31 provides that a deduction may only be made where there is "objective evidence of a pre-existing symptomatic permanent impairment in the same region at the time of the accident." The presence of age-appropriate or asymptomatic degenerative change is not sufficient.
5. The claimant has consistently denied any history of injury or dysfunction affecting the cervical spine, lumbar spine, or shoulders prior to the subject accident. That history is corroborated by the treating general practitioner, Dr Tomasevic, whose records make no reference to pre-existing complaints in the relevant anatomical areas. The claimant was in full-time employment as a formwork carpenter at the time of the accident, and no medical evidence has been adduced suggesting any prior limitation in function or treatment for musculoskeletal disorders.
6. Moreover, the contemporaneous treating specialists, including Dr Habib, Dr Guirgis, and

Dr Kuljic, accepted that while imaging disclosed degenerative changes, these had been asymptomatic prior to the accident. The Medical Assessor expressly stated that "there were no documented symptoms prior to the subject motor accident" and did not apply any deduction. 7. The Panel accepts that there is radiological evidence of degeneration but finds that there is no objective evidence of any pre-accident symptomatic impairment. The claimant's treating records, occupational history, and presentation support the conclusion that the degenerative changes were asymptomatic and functionally irrelevant prior to the motor accident. 8. Accordingly, the Panel is satisfied that no deduction should be made under cl 6.31 of the Guidelines, and the entirety of the assessed impairment (WPI 11%) is attributable to the subject motor accident. 9. Having considered all the material before it, including the competing expert reports and submissions of the parties, the Panel was satisfied that the C6 spinous process fracture, along with the other injuries under review, were caused by the subject accident and that the Medical Assessor's findings were correct. The Panel confirmed that there was no basis for any deduction under the Guidelines, and the previously assessed 11% WPI was affirmed. 10. The MAC is affirmed.