Review Panel Assessment - Treatment and Care - Causation

Replacement Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017

The Review Panel confirms the certificate of Medical Assessor David Gorman dated

1. The following treatment and care:
   • the request for a consultation with Dr Venkatesh Krishnamurthy (neurologist),

RELATES TO THE INJURY caused by the motor accident

1. The following treatment and care:
   • the request for a consultation with Dr Venkatesh Krishnamurthy (neurologist),

IS REASONABLE AND NECESSARY in the circumstances

1. The following treatment and care:
   • the request for a consultation with Dr Venkatesh Krishnamurthy (neurologist),

WILL IMPROVE the recovery of the injured person.

1. The claimant is a 43-year-old man who was injured in a motor vehicle accident on

7 June 2022. Following the accident the claimant lodged an Application for Personal Injury Benefits and thereafter sought treatment from a neurologist, Dr Krishnamurthy in respect to the cervical injury. 2. The insurer declined to meet these treatment expenses maintaining that the proposed treatments are not reasonable and necessary and do not relate to the motor vehicle accident. This included the 5/6 cervical discectomy and fusion, the consultations with

Dr Krishnamurthy and the consultation with Dr Gerrich-McGregor. 3. In his certificate dated 8 July 2024 Medical Assessor Raymond Wallace stated that he was unable to comment on whether or not the consultation with Dr Venkatesh Krishnamurthy is reasonable and necessary in the circumstances as Mr Tregear was referred to the specialist neurologist for investigation of his headache which is a condition that is outside the area of his expertise. 4. Accordingly, the claimant was examined by Medical Assessor David Gorman on 26 August 2024. In a certificate dated

8 September 2024 Medical Assessor Gorman determined that the treatment and care relates to the injury caused by the accident, is reasonable and necessary in the circumstances and will improve the recovery of the injured person. 5. The matter was considered by President's delegate, Tajan Baba who in a decision dated

28 October 2024 determined that there was a reasonable cause to suspect that the certificate was incorrect in a material respect. 6. Accordingly, the matter was referred to this Medical Panel. 7. Clause 14F of Schedule 1 of the Personal Injury Commission Act 2020 (the PIC Act) provides that the new review provisions apply in relation to a decision of a new decision-maker. A "new decision maker" is defined in cl 14A(1) of the Schedule 1 of the PIC Act. As the medical assessment, the subject of the review, was made on or after 1 March 2021, the new review provisions apply. 8. The new review provision provide that a review panel consists of two Medical Assessors and a Member assigned by the Motor Accidents Division of the Personal Injury Commission (the Commission). 9. Part 5 of the PIC Act enables the Commission to make rules with respect to its practice and procedure including proceedings before a panel reviewing a decision of a Medical Assessor. 10. Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the PIC Act. A review panel determines how it conducts and determines the proceedings and may determine the matter solely based on the written application. 11. The review of the medical assessment is by way of a new assessment of all the matters with which the medical assessment is concerned.

1. Section 57 of the MAC Act defines a "medical dispute" as a disagreement or issue to which Part 3.4 of the MAC Act applies.
2. Section 58 and s 60 of the MAC Act together with cls 1.5-1.7 of the Guidelines set out the procedures for referral to one or more Medical Assessors and the principles to be applied at such assessments.
3. The claimant was examined by Medical Assessor Margaret Gibson on 28 April 2025. The claimant attended accompanied by his partner Lara. They had arrived 30 minutes late for the assessment as they had been given an incorrect appointment time.

1. The claimant said that prior to the subject accident he had experienced some intermittent "niggly" pains in his neck and low back for which he had received chiropractic and osteopathic treatment. He had a scan of his low back in 2018 on the recommendation of his osteopath at Foundation Health (Mullumbimby Medical Centre). He said that around that time he had about six weeks of physical therapy.
2. In 2020 he had an MRI scan of his upper back and cervical spine on referral from the osteopath. This apparently demonstrated no disc pathology. Around this time he had another four weeks of osteopathic therapy.
3. So far as he could recall, he had only taken paracetamol as required for any episodes of neck or back pain.
4. He injured his left knee in 2015. He had an arthroscopy to debride the meniscus but his knee was then "good after that".
5. He said by the time of the subject accident he was taking no regular medication and had no ongoing neck or back symptoms.

1. The claimant had been working as a musician for the last 10 years and a sound therapist for over 15 years. He said he uses a "sound bed" when providing the sound therapy. He described operating the sound bed by sitting cross-legged on the ground and reaching under the instrument to operate the strings. He said the bed weighs between 30 and 40kg and he has a wheel frame to move it about. He said about 80-90% of the time it remains in the same location, but he was moving it to other locations every few weeks.
2. However, since the subject accident he has not been able to perform any sound bed therapy.
3. He has played guitar on several occasions.
4. He said he also has a leather accessories business which he runs online and uses a sales agent in Sydney. He said he has done some of this work since the accident.
5. He and his partner live on an acreage in Federal in New South Wales. He said prior to the accident he was working on the property, but has not been able to manage this since. In December 2024 the insurer had provided some land care and maintenance support.

1. The claimant was the seat-belted driver of a Nissan Elgrand people mover van. He had no passengers at the time. He was driving from his home in Federal to Byron Bay, he had left home about 8 minutes before. The trip would normally take about 20 minutes.
2. He was travelling along Coolamon Scenic Drive, which is a curving road. He had rounded a corner when a B-double truck came from the other direction and the rear trailer veered across the centre line and struck the driver's side of his van. His van was then pushed towards the steel barrier fence on the side of the road. Air bags had not deployed as there was no front end impact.
3. Mr Tregear said that after the accident he sat on the side of the road and contacted his partner. The truck driver stopped ahead and came to assist. Police and ambulance attended.
4. The ambulance report noted:

"CT 40yo M pt MVA mini van vs semi truck side swipe. 0/A pt walking down side of road with driver of other vehicle. Pt walking normally, alert and having conversation. Pt states was driving along road and a truck took the corner too tight cutting across his lane and side swipped his vehicle. Pt recalls entire event, self extracted, GCS 15, neck pain 4/10 radiating to R shoulder (declined pain relief for injury), sand bags used as reminder not to move neck. nil arbag deployment but were fitted, road speed 60kph but pt states not going nearly that speed, seat belt worn. no sudden decelerations. All other observations within normal range for pt."

1. He was conveyed by ambulance to Byron Bay Hospital. He was fitted with a soft collar. A CT scan was done of this cervical spine and he was then fitted with a hard collar before transfer to Tweed Heads Hospital for an MRI scan.
2. After the MRI scan was reviewed he was then advised that he could leave the hospital, this was several hours later. He was a bit puzzled he was let go, as he was still experiencing a lot of neck pain, particularly right-sided with pain spreading to his right shoulder. There was also pain over the right shoulder and also his right hip and there was left-sided back pain extending to the left greater than right thigh. He was given Panadeine Forte for pain.
3. The discharge summary from Tweed Hospital noted:

"40 yr old man transfer from Byron ED post MVA with neck pain. Had CT neck which showed C5/6 disc bulge and some thecal sac narrowing. Transferred to Tweed for MRI spine after Neurosurgical advice. MRI c spine - showed no acute traumatic injury ...Was rediscussed with neurosurgical team GCUH who were happy with GP follow up , no neurosurgical intervention or follow up required. No injuries on tertiary survey. Mobilised well. Plan: D/C home. Regular paracetamol / ibuprofen. Heat or cold packs to aching muscles. GP follow up. Return to ED if worsening pain/weakness to limbs or other concerns."

1. There was also imaging of chest and thoracic spine which showed no abnormalities. CT scan cervical spine had shown:

"There is no acute cervical injury noted. Disc bulging at the C5-6 level abuts the cord and narrows the thecal sac." MRI scan showed "No evidence for vertebral compression fracture or marrow contusion. No prevertebral haematoma or collection. No spinal cord injury. Multilevel mild to moderate degenerative changes in the cervical spine most prominent at C5-6 level with right foraminal narrowing and mild canal narrowing with mild neural compression as described."

1. The claimant had subsequently come under the care of his general practitioner and his osteopath. He said as the days and weeks went on, the pain extending into his right arm increased in intensity and became very severe. He described pain spreading over the top of the right shoulder into the lateral aspect of his arm and forearm and the ulnar three fingers. Over the ensuing weeks and months, the right hand became tingly and numb at times.
2. His general practitioner, Dr Khanna, on 9 June 2022 had noted motor vehicle accident with injuries and pain, psychological distress/flashbacks, motor vehicle accident two days ago, complaints of upper neck pain, bilateral shoulder pain, thoracic and lumbar back pain, bilateral hip pain and pain down back of left greater than right leg.
3. The claimant was referred to neurologist, Dr Krishnamurthy to give an opinion and to clarify the source of the headaches being experienced by the claimant.
4. He said he was eventually taking large doses of Targin, pregabalin, Panadeine Forte and

diazepam to manage the pain. He said he "never had pain like that before." 5. He was eventually referred to neurosurgeon, Dr Sergides. On 8 October 2024 Dr Sergides performed anterior cervical discectomy and C5/6 fusion at North Shore Private Hospital. 6. The claimant said there was significant improvement in his symptoms following this procedure. He had a telehealth consultation with the doctor about six weeks postoperatively but then no other reviews were planned unless required. 7. He continued to have weekly osteopathy and physiotherapy. He said he has not taken any medication for over six weeks. 8. He has been referred to a pain specialist at Physio Plus in Lismore and the appointment is scheduled for next week.

1. The claimant said the neck pain is now negligible. On further clarification, he said there is now no neck pain. He said the pain in the arm is now gone. The numbness in his right hand is reducing. His right shoulder is "okay." His upper back is "okay."
2. There is an occasional "niggle" of pain in his lower back, and some discomfort over the posterior aspect of his left greater than right thigh. His left hip is now "okay".

1. The claimant was 193cm tall and weighed 106kg. He is right-handed. He had a normal gait.
2. On examination of the cervical spine, there was a 6.5cm well healed surgical scar anteriorly. There were no suture marks. There was minimal colour contrast.
3. Neck movements were very cautious. Flexion and extension one-third normal. Lateral flexion and rotation were negligible. There was no muscle spasm or guarding.
4. On examination of the upper limbs, circumferential measurements of the arms were 35cm bilaterally and forearms measured 32.5cm on the right and 32cm on the left. There were normal reflexes, power and sensation apart from some reduced sensation over the lateral right forearm and the ulnar fingers.
5. On examination of both shoulders, movements were as follows:

1. On examination of the upper back, there was no tenderness. Rotation was to three-quarters normal range bilaterally. There was no asymmetry, muscle spasm or guarding.
2. On examination of the lower back, there was slight tenderness over the lower lumbar spine. Flexion and extension were to half-normal range, lateral flexion was to two-thirds normal range bilaterally, rotation was to three-quarters normal range bilaterally. There was no asymmetry, muscle spasm or guarding. Straight leg raise was 50° bilaterally. Sciatic stretch was negative.
3. On examination of the lower limbs, circumferential measurements were 48cm bilaterally at the thighs, and maximal calf girth was 41cm bilaterally. There was normal power, sensation and reflexes bilaterally.
4. On examination of both hips, there was no specific tenderness. Active movements were as follows:

1. The material identifies annular tear present at C4/5 and C5/6. The panel is satisfied that the medical material supports the contention that the claimant sustained an injury to his cervical spine in the subject accident. This is borne out by the notes from Tweed Hospital, the imaging obtained of the claimant's cervical spine and the history given by the claimant. The panel is not satisfied that a note in the claimant's discharge summary which states "no acute traumatic injury" was detected sufficient to overturn the panels finding on examination, the history given by the claimant and the weight of medical and radiological material considered by the panel.
2. The panel was not satisfied that a note in his medical records dated 5 February 2020 (two and a half years before the motor vehicle accident) is indicative of a pre-existing medical condition such as like to cause the significant complaints made by the claimant following the motor vehicle accident.

1. Mr Tregear was injured in the subject accident on 7 June 2022. There was early evidence of complaints to his general practitioner, Dr Khanna, on 9 June 2022 of neck pain, upper and lower back, bilateral shoulder pain and bilateral hip pain. The general practitioner had felt the headache may be cervicogenic, in other words arising from the neck injury. But in order to be certain about the headache diagnosis and exclude other causes, he referred him to neurologist, Dr Venkatesh Krishnamurthy. Dr Krishnamurthy examined him on

18 November 2022. The doctor noted that "He describes constant headaches which varies in intensity from 2-7/10 and this has been ongoing since this accident. He denies any prior history of headaches" and "he meets the diagnostic criteria for a diagnosis of persistent headache attributed to whiplash." He had prescribed amitriptyline for the headache and at his second consultation (12 April 2023) he notes "he has progressed into a transformed migraine." 2. These consultations related to the subject accident, as they were originally cervicogenic and so secondary to his cervical spine injury. There was no prior history of headache, and specific headache symptoms had arisen within days of the subject accident. The consultations were reasonable and necessary as they were conducted to formulate a plan for specific targeted therapy, which was different to the treatment required for the neck injury. The consultations would improve recovery, as this was therapy particularly targeted to the headache diagnosis. 3. The following treatment and care relates to the injury caused by the motor accident: * the request for a consultation with Dr Venkatesh Krishnamurthy (neurologist). 4. The following treatment and care is reasonable and necessary in the circumstances: * the request for a consultation with Dr Venkatesh Krishnamurthy (neurologist). 5. The following treatment and care will improve the recovery of the injured person: * the request for a consultation with Dr Venkatesh Krishnamurthy (neurologist).

1. The consultation with Dr Venkatesh Krishnamurthy relates to the injuries caused by the accident, is reasonable and necessary in the circumstances and would improve the recovery of the claimant.