A brief statement is attached setting out the Commission's reasons for the determination.

1. The applicant Mr Roustaei was employed by the respondent as a process worker cutting and polishing glass sheets for about two and a half years until his injury on 31 January 2020.
2. The applicant lifted an extremely heavy sheet of glass with a co-worker for polishing and experienced significant lower back pain radiating down his right leg. Liability for the applicant's low back pain was accepted on 22 May 2020.
3. Liability was disputed for alleged consequential injuries to the sacroiliac joint and right ankle and related medical treatment by a notice issued under s 78 of the Workplace Injury Management and Workers Compensation Act 1998 (1998 Act) on 5 February 2024.
4. The decision was maintained following internal review on 24 December 2024.
5. The applicant lodged an Application to Resolve a Dispute (ARD) with the Personal Injury Commission (Commission) on 20 May 2025 claiming medical or related expenses as a result of injury, including for proposed sacroiliac arthrodesis and in-patient costs.
6. The dispute was listed for conciliation conference and arbitration hearing on 20 August 2025.

1. The parties agree the following issues remain in dispute:

(a) whether the applicant sustained a sacroiliac joint injury on 31 January 2020 as the result of his employment pursuant to ss 4, 9A and/or 4(b) of the Workers Compensation Act 1987 (1987 Act), and

(b) whether the applicant is entitled to payment of the sacroiliac arthrodesis (fusion) proposed by Associate Professor Woodgate pursuant to s 60 of the 1987 Act.

1. The parties appeared for conciliation conference and arbitration hearing by audio visual link (MS Teams) on 20 August 2025. Mr Paul Stockley of counsel appeared for the applicant instructed by Ms Amy Trieu, legal practitioner. Mr Andrew Parker of counsel appeared for the respondent instructed by Ms Nina Israil, legal practitioner. Ms Razaghi, interpreter, was present, as was Mr Massih.
2. During conciliation the applicant's Application to Lodge Additional Documents dated

13 June 2025, the applicant's Application to Lodge Additional Documents dated

5 August 2025 and the respondent's Application to Lodge Additional Documents dated

19 August 2025 were admitted into evidence by consent. 3. The respondent's counsel advised that due to the operation of cl 44 of the Workers Compensation Regulation 2016 it sought to rely on the reports of Dr Machart only with respect to the histories taken and would not refer to any conclusions expressed by Dr Machart. 4. I am satisfied the parties to the dispute understand the nature of the application and the legal implications of any assertion made in the information supplied. I have used my best endeavours in attempting to bring the parties to the dispute to a settlement acceptable to all of them. I am satisfied the parties have had sufficient opportunity to explore settlement and that they have been unable to reach an agreed resolution of the dispute.

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

(a) ARD and attached documents;

(b) Reply and attached documents;

(c) applicant's Application to Lodge Additional Documents dated 13 June 2025 and attached documents (ALAD 1);

(d) applicant's Application to Lodge Additional Documents dated 5 August 2025 and attached documents (ALAD 2); and

(e) respondent's Application to Lodge Additional Documents dated 19 August 2025 and attached documents (ALAD 3).

1. No application was made to adduce oral evidence.

1. In his statement of 17 April 2024 the applicant describes working full time for the respondent from Monday to Friday between 7am and 4pm using one machine to cut glass and another machine to polish glass.
2. The applicant manually placed the glass sheets on the cutting machine to be cut via automation. Once it was cut he manually removed the offcut which he placed in a bin and he then manually lifted the glass to stack it.
3. He lifted and removed about 100 to 200 sheets on and off the glass cutting machine each shift.
4. To polish a glass sheet the applicant manually handled it and laid it on one side to be polished via automation. When that was completed he manually lifted it off the machine and placed it back on the machine so the other side could be polished. This was repeated four times.
5. The applicant polished anywhere between 10 to 100 sheets of glass per shift, with fewer sheets handled normally due to the sheets being heavier and taking longer to polish.
6. The glass sheets came in a vast range of different sizes which were cut to size as per individual client orders. The glass ranged in thickness from 6mm to 8mm and up to 12mm. It was heavy and the larger it was the more awkward it was to handle.
7. In mid-2018 the applicant experienced pain in his back. This came on gradually from the nature of his work with the respondent. When the pain did not go away he consulted his general practitioner Dr Noorzad on about 25 September 2018 about his back pain.
8. Dr Noorzad gave him a certificate of capacity for restricted duties 8 hours a day. He was told at work he had to do his normal duties and hours and the certificate was handed back to him.
9. The applicant continued to work putting up with the pain until 28 January 2020. That day he lifted a large sheet of glass over 2000mm long and 1200mm, 12mm in thickness. The glass had to be polished and the applicant had to lift it in a team lift with a co-worker. They each took one end.
10. The sheet was lying on its edge and they picked it up with an underhand lift. As he was lifting it the applicant experienced significant pain in his lower back. He continued the lift and placed the sheet onto the machine and then continued with his normal duties. His back was in a great deal of pain radiating down into his right leg. After some hours he told his boss about the injury and he left work to see a doctor.
11. Dr Noorzad told him he had to change and find an easy job. The applicant said he could not find another job and his experience was in glass. Dr Noorzad referred the applicant for an MRI and later to Dr Van Gelder, neurosurgeon.
12. The applicant went to work the next day to talk to his boss. He said he was injured and could not work. The following day when he went back to work to speak about his injury again he was given a letter of termination. He has not worked since.
13. He continues to have significant back pain radiating into his right leg.
14. In his supplementary statement of 3 February 2025 the applicant confirms he suffered an injury to his lower back which resulted in consequential injuries to both hips, ankles, knees, right foot and buttocks.
15. He has received treatment from Dr Anil Nair, spinal surgeon, who referred him for an updated MRI of his lumbar spine, a bone scan and an MRI of his left hip.
16. In around October 2021 Dr Nair referred him for a right sacroiliac joint injection to help identify where the pain was coming from. In around February 2022 Dr Nair recommended radiofrequency ablation of his left sacroiliac joint and encouraged him to seek a second opinion. Dr Nair carried out the ablation on 8 June 2022 but the applicant continued to experience lower back discomfort and in both knees. He was referred for an MRI of his lumbar spine.
17. Dr Nair suggested diagnostic blocks as a treatment for the applicant's lower back pain and one was carried out on 26 October 2022 at L5/S1. By December 2022 the applicant continued to experience pain in his left sacroiliac joint and Dr Nair informed him the effects to the radiofrequency ablation had worn off.
18. Since 31 January 2020 the applicant has had five or six injections in his lower back and hip. These did not provide much pain relief. He had another two or three injections in his lower back, the last by Associate Professor Woodgate in 2023, in an attempt to alleviate his symptoms.
19. The applicant's lower back pain worsened. Given the lack of effectiveness he was recommended to undergo fusion surgery.
20. Associate Professor Woodgate provided referrals for a left minimally invasive sacroiliac arthrodesis and right hindfoot injections which were rejected by the insurer.
21. Dr Nair provided a second opinion and advised the applicant he had exhausted all alternative treatments and as a result he recommended fusion surgery for his lower back as he believed it would help alleviate symptoms related to his sacroiliac joint.
22. The applicant has also consulted Dr John Rooney, orthopaedic surgeon.
23. The applicant's symptoms include a hot, burning sensation and pins and needles and pain in his lower back. He has difficulty walking or sitting for longer than 15 minutes and struggles to stand for more than two minutes due to severe pain. The pain radiates into his hips and sometimes his entire legs.
24. He has a constant burning sensation and numbness in his left hip with tingling sensations and pins and needles which worsens when he lies down. He occasionally experiences numbness, a hot burning sensation and pain in his right hip. He also has pain in his ankles, right foot and buttocks. He suffers with psychological symptoms.
25. He lists the painkillers, pain patches and other medications he uses to manage his symptoms.
26. Due to his injuries the applicant is unable to find employment or engage in regular work activities.
27. On 3 July 2025 the applicant provides a further statement. He describes seeing Dr Noorzad in 2018 for his lower back pain that travelled to his buttocks and through his hips into his groin. He does not recall his general practitioner explaining the difference between his lower back and sacroiliac joint, and he did not think there was a distinction because they are so close to each other.
28. At the time the applicant understood the injury was to his lower back. The pain soon spread to other parts of his body including his hips, groin area, buttocks, ankles and knees. He does not think he would have been able to distinguish if the pain was coming from his lower back or sacroiliac joint.
29. He trusts his doctors and always follows their advice because he wants to recover and stop feeling pain. When Dr Nair suggested radiofrequency ablation he thought it was for his lower back since that is where the pain was.
30. Despite the radiofrequency ablation of his left sacroiliac joint on 8 June 2022 he still had discomfort in his lower back and both knees which led Dr Nair to send him for an MRI of his lumbar spine. Now he thinks the issue could also be with his sacroiliac joint. Dr Nair then suggested diagnostic blocks to treat his lower back pain. He had a corticosteroid injection in his lumbar spine on 26 October 2022.
31. In December 2022 when he still had pain in his left sacroiliac joint and lower back, Dr Nair told the applicant the effects of the radiofrequency ablation had worn off.
32. Since 31 January 2020 the applicant has had five to six injections in his lower back and hip but they did not provide much relief. Dr Nair gave him another two to three injections in his lower back hoping to reduce the pain. The last injection was administered by Associate Professor Woodgate in 2023.
33. The applicant now thinks the injections were actually for his sacroiliac joint not his lower back. Unfortunately the injections did not help and actually made his lower back pain worse and he is hesitant to try any more injections. Because they did not work he was later recommended for left minimally invasive sacroiliac arthrodesis. He assumed this was for his lower back.
34. He was referred for the surgery by Associate Professor Woodgate on 14 August 2023.
35. The applicant sought a second opinion from Dr Nair who confirmed he had tried all other treatments including multiple injections and physical therapy. Dr Nair recommended the surgery believing it would help reduce pain in his sacroiliac joint.
36. The applicant still believes his pain is related to his lower back which he thinks includes his sacroiliac joint. He finds it difficult to tell if the pain is related to his lower back or sacroiliac joint as they are so close and feel similar.
37. The applicant constantly experiences a hot, burning sensation, along with pins and needles and pain in his lower back, and he struggles to stand for more than two minutes because of severe pain. He has difficulty walking or sitting for longer than 15 minutes as the pain becomes unbearable, radiating into his hips and sometimes his entire legs. The pain in his lower back is worsening but he cannot always pinpoint where it is coming from.
38. His doctors have advised the applicant the injuries to his lower back and sacroiliac joint are due to the heavy nature and conditions of his employment.

1. Dr Nair's reports between 15 September 2020 and 12 May 2025 are initially regarding treatment of the applicant's lower back pain and right lower extremity radicular symptoms.
2. On 25 May 2021 Dr Nair reports the bone scan and MRI are suggestive of sacroiliac joint dysfunction and he suggests sacroiliac joint blocks. He reports on a temporary good response to a left sacroiliac joint corticosteroid injection on 1 February 2022. On

1 February 2022 and on 7 June 2022 Dr Nair strongly encourages a second opinion on suggested radiofrequency ablation. 3. On 8 June 2022 Dr Nair provides an operation report for radiofrequency ablation of the left sacroiliac joint. A repeat MRI was requested by Dr Nair on 19 July 2022. 4. On 13 September 2022 Dr Nair reports he has discussed options including diagnostic blocks and the applicant is keen to proceed. There is an operation report dated 26 October 2022 for lumbar diagnostic blocks (L5/S1 bilateral transforaminal block and epidural corticosteroid). 5. The applicant remained troubled by left sacroiliac joint pain on 6 December 2022 and Dr Nair reports the radiofrequency ablation has worn off. Dr Nair asks for a repeat bone scan and depending on the result surgery may be indicated. 6. In his medico legal report of 6 December 2024 Dr Nair opines the surgery recommended by Associate Professor Woodgate is reasonably necessary, and as the diagnosis has been established he had recommended an identical procedure. The applicant has exhausted all alternatives including multiple corticosteroid injections into the sacroiliac joint as well as extensive physical therapy. Dr Nair notes two independent and separate orthopaedic spinal surgeons have come to the conclusion that the procedure will be predictable in terms of assuaging symptoms of the sacroiliac joint. 7. Dr Nair comments that Associate Professor Neil, qualified by the respondent, is a knee surgeon as opposed to a spinal surgeon and he disagrees with his opinion. The literature is supportive of the procedure when the pain generator is narrowed, as is the case with the applicant. 8. In his report of 12 May 2025 Dr Nair opines employment is the main contributing factor to the pathoanatomic of the left sacroiliac joints. The proposed surgery is reasonable and necessary and has been recommended by two separate surgeons. It is likely that both the applicant's lower back injury and hip injury were injured due to the nature and conditions of the work.

1. On 4 August 2021 Dr Rooney provides his opinion regarding the applicant's work injury. The imaging supports inflammation in both sacroiliac joints. He recommends cortico-steroid injection in his left sacroiliac to ascertain whether there is any improvement of those symptoms, followed by an injection into the right sacroiliac joint to differentiate the contributions of pain from the left and right, and an injection into the left hip joint six weeks later for a labral tear.
2. On 31 August 2022 Dr Rooney reports the applicant found no benefit from the injections. His injuries are probably one of a repetitive nature of lifting and all the heavy work in the glass factory, let alone the specific injury itself. He was going to organise another bone scan and CT scan to include the lumbar spine and sacroiliac joint, both hips and both knees.
3. On 9 November 2022 Dr Rooney recommends the applicant see Associate Professor Woodgate, a highly experienced surgeon particularly with the sacroiliac joint in association with the pelvic bone and the hip, for review and management,
4. Dr Rooney agrees on 11 May 2023 the sacroiliac joint is an issue and he would be interested to know how the applicant goes with the injections into both parts, the synovial and the fibrous ligamentous of the left sacroiliac joint.

Associate Professor Ian Woodgate, treating orthopaedic surgeon

1. Associate Professor Woodgate first saw the applicant on 23 January 2023 and first reports to Dr Rooney on 6 March 2023. His opinion is the applicant likely has bilateral sacroiliac dysfunction/instability, worse on the left, on a background of recurrent heavy lifting/minor trauma.
2. Separately the applicant also has precocious degeneration in both hips, worse on the left, with a left hip labral tear and possible pincer femoroacetabular impingement, and again his work has probably contributed/exacerbated/accelerated this. There is also some mild lumbar spondylosis. Associate Professor Woodgate requests further imaging studies.
3. On 26 April 2023 Associate Professor Woodgate requests left sacroiliac intraarticular injection with steroid and on 14 August 2023 left minimally invasive sacroiliac arthrodesis.
4. On 12 December 2023 Associate Professor Woodgate is asked to comment on Associate Professor Neil's report. He notes Associate Professor Neil in fact noted some sacroiliac tenderness but did not comment on the previous injections undertaken for the sacroiliac joint on 10 July 2023 which dramatically improved his pain in the local anaesthetic phase. There was no reference made to the previous assessments of Dr Rooney who had reviewed the applicant for at least 18 months, particularly with regard to his sacroiliac joint pathology.
5. On 10 June 2025 Associate Professor Woodgate's opinion remains that the applicant has bilateral precocious sacroiliac dysfunction and instability, worse on the left, as a result of the nature of his work. Having undertaken a left sacroiliac injection which reduced his pain there is definitive proof that this is the major source of his symptoms.
6. Based on the positive clinical history, examination and diagnostic injection Associate Professor Woodgate feels surgery is entirely reasonable for the sacroiliac joints.

1. Dr van Gelder reports to Dr Noorzad on 18 May 2020 that the MRI of the lumbar spine on

5 February 2020 is essentially normal considering his age. There are no signs of traumatic injuries, or deformity or instability or nerve compression for contemplating interventions or neurosurgical treatments. The applicant should continue with standard rehabilitation treatments.

1. Ms Moubarak provides four reports between 8 March 2022 and 16 October 2023, three of which are addressed to the Department of Foreign Affairs. These do not appear relevant to the issues to be determined in these proceedings.

1. Mr Madz reports on 19 January 2021 the applicant commenced physiotherapy in

August 2020 with two sessions a week, totalling 36 sessions so far. 2. The applicant was treated for lumbar spine pain and also complained of hip and lower abdominal pain for the last few treatments. Mr Madz asks that further investigations be considered of his bilateral hips and lower abdominal region. 3. Mr Madz recommends further orthopaedic review of the applicant's bilateral hips on

1. Mr Nasso reports on 18 September 2020 the applicant presented with lower back and lower limb pain after his work injury, with bilateral radicular symptoms and pain in the lower shin. He recommends training to assist with gait mechanics, overall mobility and stability, and two exercise physiology sessions per week for four weeks.

Dr Mohd Daud Noorzad, treating general practitioner

1. Dr Noorzad reports on 3 June 2020 the applicant initially consulted him regarding back pain in 2018 and again on 28 January 2020 due to heavy working. The MRI results were discussed with him and he was referred to a physiotherapist for his back pain.
2. On 12 February 2020 the applicant had lower back pain and numbness in his legs and he was referred to Dr van Gelder for an opinion on his chronic and persistent back pain.

1. On 17 November 2020 Dr Nikunj Parikh, treating pain physician, reports on the applicant's lower back pain. Dr Parikh notes bilateral hip pain with some tenderness over the sacroiliac joint bilaterally as well as tenderness over the lower L4/5 region. He describes possible sacroiliac joint dysfunction and trochanteric bursitis.
2. On 23 March 2022 Dr Parikh reports the applicant continues to have ongoing pain particularly over his left hip and lower back region following corticosteroid injection to the sacroiliac joints and left hip. The treatment plan includes considering pulsed radiofrequency to bilateral sacroiliac joints and left hip.
3. Dr Ijaz Khan, Director of Medical Services with InjuryCare, refers the applicant to Dr James Linklater on 18 August 2021 for the interventions and imaging requested by Dr Rooney.
4. Dr Naresh Verma, treating psychiatrist and occupational physician, provides a report on

15 June 2022 regarding continuing psychological treatment. On 25 February 2025 Dr Verma reports the applicant has adjustment disorder with depressed and anxious mood.

1. The radiology reports with the ARD include a whole body scan of 2 December 2020 containing a clinical note of possible sacroiliac joint dysfunction or trochanteric bursitis as well as lower back pain. The conclusion is the cause of the applicant's symptoms was not identified.
2. The bone scan of 16 April 2021 concludes the applicant has mild bilateral sacroiliac joint arthropathy. A bone scan whole body with SPECT/CT on 1 November 2022 concludes there is no evidence for active sacroiliitis. An X-ray of the pelvis, sacroiliac joints and both hips on 26 August 2021 demonstrates no definite radiographic abnormality of the sacroiliac joints.
3. A CT guided left sacroiliac joint injection was carried out on 26 April 2021 and again on

22 November 2021. On 10 July 2023 a CT S1 joint injection was carried out into the left sacroiliac joint in its upper ligamentous and lower synovial portions. A right CT-guided sacroiliac joint steroid injection was carried out on 7 October 2021.

1. The clinical records of Dr Noorzad printed on 30 April 2021 are with the ARD. The applicant's complaints of lower back pain are recorded on 25 September 2018, 25 January 2020 and on 28 January 2020 when it was worse after lifting heavy glass windows. The records of the applicant's complaints of back pain continue to 27 July 2020.
2. The clinical records of Dr Ijaz Khan between 26 August 2020 and 15 March 2021 record treatment for acute chronic back pain.

1. Dr Noorzad certifies the applicant as having capacity for work for eight hours a day five days a week between 25 September 2018 and 9 October 2018 for lower back paid radiating to his right buttock.
2. Between 12 May 2020 and 12 June 2020 Dr Noorzad certifies the applicant as having capacity to work 4 hours a day 3 days a week due to lower back pain.
3. Dr Khan certifies the applicant as having capacity for unrestricted hours of work from

4 November 2020 to 16 December 2020, and from 15 March 2021 and 14 April 2021, with restricted capacity for activities. 4. Dr Khan includes bilateral sacroiliac joint dysfunction as a diagnosis in his certificates from 13 May 2021 to 29 April 2024.

1. Accounts and receipts for medical or related expenses are with the ARD including fees for lumbar spine and sacroiliac joints MRI and travel costs.
2. Associate Professor Woodgate's quote for sacroiliac arthrodesis (fusion) - one side dated

17 February 2025 includes fees payable to him of $8,592 as well as anaesthetist and private hospital in-patient fees. 3. The Easy Sydney Private Hospital fees dated 24 February 2025 include orthopaedic and anaesthetist fees, three days accommodation, prosthesis and Novaboost fees, totalling $21,617.

1. The s 78 notice of 5 February 2024 and the internal review notice of 24 December 2024 are with the Reply.

Dr Frank Machart, independent orthopaedic surgeon

1. On 3 February 2022 Dr Machart provides a report including a history of the applicant's work with the respondent, his back injury on 31 January 2020 while lifting heavy lead glass when he experienced sharp pain in the lower back and right buttock, that he stopped work and was terminated and has not worked since. His general practitioner referred the applicant to Dr Rooney, orthopaedic surgeon and he saw Dr Nair, spinal surgeon.
2. The applicant had three cortisone injections including two to the hip. There was no improvement and he reported no benefit from treatment or rest. The applicant admitted to having suffered some back pain prior to the injury and maintained it was not severe and he was checked out by doctors.

Associate Professor Michael Neil, independent orthopaedic surgeon

1. Associate Professor Neil reports on 30 October 2023 the applicant presents with generalised non-specific lower lumbar and sacroiliac pain that commenced in 2019 and which he related to a lifting event as a glass cutter on 14 January 2020. The pain was unresponsive to various modalities of treatment including physiotherapy, multiple image guided injections and pharmacological agents.
2. The applicant had been diagnosed with severe post-traumatic stress disorder and anxiety and depression. His examination was not convincing of any significant organic pathology and his investigations are remarkably normal.
3. Associate Professor Neil diagnosed functional low back pain and severe anxiety which may be post-traumatic.
4. Associate Professor Neil does not believe there is any evidence of objective pathology in the sacroiliac joint, and he does not believe that these diagnoses are related to a work injury on

31 January 2020. In this opinion the applicant exhibits many signs of functional overlay. 5. Associate Professor Neil does not believe the minimally invasive sacroiliac arthrodesis on the left side is even necessary or rational. No alternative or additional treatment will improve the applicant. 6. The proposed surgery will more likely than not result in permanent impairment, and the supporting literature for the outcome of sacroiliac arthrodesis is guarded in such a patient in Associate Professor Neil's view. 7. In his supplementary report of 28 March 2024 Associate Professor Neil says the applicant has no capacity for work. The applicant demonstrates significant functional overlay with no demonstrable organic pathology. It is most unlikely in Associate Professor Neil's opinion that the effects of the condition will ever resolve. 8. In his report of 18 August 2025 Associate Professor Neil's diagnosis is mechanical low back pain associated with minor facet joint arthrosis (pre-existing work related permanent aggravation). There is no structural abnormality on his imaging and Associate Professor Neil cannot identify any verifiable pathology on clinical examination or on imaging to explain the applicant's current symptoms. His complaints appear grossly disproportionate to objective identifiable pathology in the doctor's opinion. 9. With respect to the proposed sacroiliac surgery, Associate Professor Neil notes the second bone scan of 1 November 2022 came back normal, the applicant cannot remember profound improvement from the injection Associate Professor Woodgate refers to, Associate Professor Neil found marked functional component to the applicant's presentation, and Associate Professor Woodgate has enthusiasm for the proposed procedure which is largely unexplained particularly as it still remains controversial. 10. Associate Professor Neil finds there is no work-related injury of both sacroiliac joints, right ankle or both hips. These conditions are not consequential to the applicant's back injury and are age-related and pre-existing. He does not believe this is a consequential condition to the lumbar spine. Associate Professor Neil cannot find on clinical examination or on his imaging verifiable organic pathology which would explain his symptoms. 11. The applicant does not satisfy the criteria for successful sacroiliac fusion in Associate Professor Neil's opinion. For it to work the pain needs to be localised to the sacroiliac joint with verifiable sacroiliac joint dysfunction due to degenerative sacroiliitis or sacroiliac joint disruption. The applicant's pain is diffuse and nonorganic and his examination suggests a hyperpathic response to light touch. 12. Associate Professor Neil does not consider the surgery will provide benefit or be effective. The surgery costs of $30,209 are not cost effective. It appears to be a controversial operation and Associate Professor Neil does not consider the proposed surgery to be reasonable and effective.

Dr Nikunj Parikh, treating pain medicine physician

1. Dr Parikh's reports of 17 November 2020 and 23 March 2022 are referred to above.
2. On 25 September 2024 Dr Parikh reports to Dr Khan of an impression that the applicant has chronic pain with left hip and left sacroiliac joint dysfunction.
3. The applicant would like to see another neurosurgeon as he believes Associate Professor Woodgate's suggested fusion of the left sacroiliac joint would be helpful. Dr Parikh's opinion is that having a second opinion with a neurosurgeon with regards to his chronic lumbar pain is reasonable.

1. The respondent relies on Dr Rooney's reports of 4 August 2021, 31 August 2022 and

1. Dr Nair's reports of 1 February 2022, 7 June 2022, 13 September 2022, his medico legal report of 6 December 2024 and the operation report of 8 June 2022 are also with the Reply and these are referred to above.
2. Dr Nair reports on 11 August 2022 the applicant injured himself as a consequence of the nature and conditions of his work while working for the respondent, he diagnoses lumbar degenerative disc disease with clinical and radiological evidence of left sacroiliac joint dysfunction. It is almost certain that the left sacroiliac dysfunction was permanently aggravated by the nature and conditions of his work duties and his work duties were the main reason for the aggravation.
3. On 5 November 2024 Dr Nair reports the applicant had had multiple interventions and discussed options including sacroiliac joint fusion. The applicant had previously had good albeit ephemeral relief from corticosteroid injections and radio frequency into the sacroiliac joint regions. Dr Nair understood Associate Professor Woodgate recommended bilateral S! fusions and Dr Nair asked the applicant to undergo repeat medical imaging prior to making a decision on surgical treatment.
4. On 3 December 2024 Dr Nair reports the S1 blocks have improved symptoms dramatically for a few weeks so the pain generator is corroborated. The options would be repeat blocks that he could have two to three times a year. The definitive treatment would be a sacroiliac fusion and the applicant is keen to proceed.
5. Dr Nair requested surgery on 3 December 2024. In view of the permanent and anatomical aggravation as evidenced by objective patho-anatomy, Dr Nair's view is the aggravation can only be rectified surgically and as such he requested funding for left sacroiliac joint fusion.

Associate Professor Ian Woodgate, treating orthopaedic surgeon

1. Associate Professor Woodgate's reports dated 6 March 2023, 14 August 2023 and 12 December 2023 are referred to above.
2. On 5 February 2024 Associate Professor Woodgate provides further information to the insurer. When asked how the proposed sacroiliac surgery is reasonably necessary for the applicant's work related condition, Associate Professor Woodgate says after multiple requests the applicant finally underwent a left sacroiliac injection on 10 July 2023 which dramatically improved the pain during the anaesthetic phase, confirming this was a major source of his pain, although there were other sites of pain. On the balance of probabilities Associate Professor Woodgate says the applicant's work has been the major source of the precocious degeneration in multiple joints.
3. The staged sacroiliac surgeries have the capacity to relieve the majority of the applicant's pelvic pain. In Associate Professor Woodgate's opinion the applicant is likely to require staged bilateral sacroiliac surgery which is likely to alleviate more than 90 percent of his pain and limitation as a consequence of the injury.
4. Should the applicant go through successful staged sacroiliac surgery Associate Professor Woodgate suspects he will be able to return to most of his normal work duties.

Dr Naresh Verma, treating psychiatrist and occupational physician

1. Dr Verma reports on 16 April 2024 the applicant has had a lot of injections without much relief so far. Dr Verma's impression is adjustment disorder with depressed and anxious mood with pain and poor social supports are a perpetuating factor.
2. On 11 June 2024 Dr Verma's report is in similar terms. On 3 September 2024 Dr Verma notes ongoing pain and that the applicant is still awaiting approval for surgery.

1. Reports of the whole body scan of 2 December 2020, the lumbar spine MRI of

10 February 2021, the bone scan of 16 April 2021, left hip and sacroiliac joints MRI of 19 April 2021, the X-ray of the pelvis, sacroiliac joints and both hips of 30 August 2021, and the steroid injections of 9 October 2021 and 22 November 2021 attached to the ARD are also with the Reply.

1. The applicant made oral submissions which have been recorded and form part of the Commission's record. These are set out below.
2. The primary issue is the question of causation and injury. Dr Nair on 12 May 2025, Dr Rooney on 31 August 2022 and Associate Professor Woodgate on 26 April 2023 all provide positive expressions of opinion regarding the relationship between the sacroiliac condition and work.
3. The s 78 dispute notice was not issued until 5 February 2024 so there was no controversy about the nature of the injury until then, and that was despite the fact the respondent had procured an opinion from Dr Machart.
4. The applicant's treating medical practitioners had no reason to think there was any controversy about the way in which they were proceeding. Dr Rooney in particular recommended a series of diagnostic and treating options and consulted the insurer on the way through as to their propriety and the fact the insurer would be paying for them.
5. The management of the applicant's condition was uncontroversial until February 2024. The treating doctors are simply expressing their opinions in the context of the treatment regime they are applying for. These are not adversarial expressions of advocates.
6. Dr Nair reports to Dr Khan that the applicant's pain seems to be more in the distribution of the left hip and sacroiliac joint. As the case unfolded investigations are directed to that particular area and diagnostic and treating injections were applied. The sacroiliac joint was always being investigated and there was no controversy until quite recently.
7. Dr Nair comments on Associate Professor Neil's opinion on 6 December 2024. Dr Nair says;

"[w]e have confidently narrowed down the paint (sic) generator. Two independent and separate orthopaedic spinal surgeons have come to the conclusion that the procedure will be predictable in terms of assuaging symptoms from his sacroiliac joint."[1]

1. On 12 May 2025 Dr Nair diagnoses the applicant's hip injury as secondary left joint dysfunction and employment is the main contributing factor to the pathoanatomy of the left sacroiliac joints. Dr Nair says it is not unusual for the sacroiliac joint to be injured at the same time as the lower portion of the vertebral column and the injuries were due to the laborious nature and conditions of the applicant's work duties, which is the case the applicant presents.
2. Dr Rooney took a history in August 2021 of pain to his lumbar spine and radiating towards both sacroiliac joints, more so on the left. An MRI scan had been directed to both left and right sacroiliac joints and he recommended the injection of local anaesthetic and cortico-steroid into the left sacroiliac joint. This is to ascertain whether there is any improvement in symptoms, and if there is a response the clinicians are entitled to think the seat of the symptoms has been identified.
3. Dr Rooney continues to write to Icare providing an injury management type of opinion.
4. On 31 August 2022 Dr Rooney reports on the injections and on 9 November 2022 he reviews some radiology and recommends the applicant sees Associate Professor Woodgate.
5. Associate Professor Woodgate on 6 March 2023 offers a diagnosis of bilateral sacroiliac dysfunction and instability, worse on the left, on a background of recurrent heavy lifting, and he talked about further diagnostic steps to be taken.
6. On 26 April 2023 Associate Professor Woodgate in a letter to Dr Rooney sought consent for a CT-guided diagnostic injection to the left sacroiliac joint, so the investigation is narrowing down. He mentions he would be discussing the options of either prolotherapy or perhaps minimally invasive sacroiliac arthrodesis.
7. Associate Professor Woodgate says the applicant has precocious degeneration including in his hips, lumbar spine and knees and the latest X-rays certainly suggest post traumatic sacroiliac instability from his previous heavy work commitments. Associate Professor Woodgate then proposes the left sacroiliac arthrodesis.
8. On 10 June 2025 Associate Professor Woodgate's opinion is unshaken. He has no doubt the applicant has bilateral precocious sacroiliac dysfunction on the background of recurrent heavy lifting, bending and twisting, specifically related to his work. He confirms his opinion and his support for the proposed surgery.
9. The applicant's submission is that the conclusions reached by the three doctors who support his case are supported by reasoning.
10. The respondent's case is that Associate Professor Neil does not accept there was any injury.
11. Associate Professor Neil saw the applicant in October 2023 and he says he does not believe there is any evidence of objective pathology in the sacroiliac joint.
12. The applicant's submission is that this is difficult to accept in the face of significant and careful diagnostic enquiries that have been made by the treating clinicians from the beginning of 2021 including radiology and the application of injections.
13. If Associate Professor Neil is right then there is no pathology and no need for an arthrodesis but the applicant submits that is incorrect.
14. Associate Professor Neil in his report of 18 August 2025 records the applicant's symptoms although he was dismissive of them because they were so significant. The radiology was reviewed and on this occasion he makes a diagnosis of back pain but his diagnosis does not extend to the sacroiliac joint. Associate Professor Neil says it would appear the applicant has scan evidence of bilateral mild inflammatory sacroiliitis which is now resolved but it is not related to work.
15. The applicant's submission is that Associate Professor Neil's conclusions are unpersuasive and he does not provide any reasoned basis for the conclusion he reached in the face of the treating medical opinions.
16. There is no difficulty in the applicant's submission in finding on the balance of probabilities the applicant sustained an injury to his left sacroiliac joint and that the symptoms that it produces warrant the arthrodesis that is proposed by Associate Professor Woodgate.

1. The respondent made oral submissions which have been recorded and form part of the Commission's record. These are set out below.
2. The respondent submits there a problem is whether there is an injury that needs any adjustment, and secondly whether the relevant reason for that, that there was reasonable response from the injections, can be made out.
3. The applicant could have relied on Dr Machart's opinion but he has not so you can safely assume Dr Machart does not help the applicant's case in the respondent's submission.
4. The respondent disputes the applicant's submission that the applicant complained of sacroiliac pain within three months of his injury. Dr Nair's report including that complaint is dated March 2021. The underlying premise of the applicant's case cannot be made good as the complaint of the condition was made some nine or ten months after the applicant ceased work.
5. The absence of a record in the clinical notes and reports of sacroiliac pain cannot be explained. The doctors and specialists should know the difference between the lumbar spine and the sacroiliac. The absence of specific mention of the sacroiliac pain for some nine or ten months is very significant to the underlying assumptions and opinions of the treating doctors.
6. The respondent submits that memories are fallible over time and refers to Onassis and Calogeropoulos v Vergottis.[2] In that case it was said that witnesses, especially those who are emotional and think they are morally in the right tend very easily and unconsciously to conjure up a legal right that did not exist. It is a truism often used in accident cases that with every day that passes the memory becomes fainter and the imagination becomes more active. For that reason a witness, however honest, rarely persuades a judge that his present recollection is preferable to that which was taken down in writing immediately after the accident occurred. Therefore contemporary documents are always of the utmost importance.
7. The applicant has made a statement fairly early on not complaining about the sacroiliac at all. In his last statement, some five years after going off work, he seems to suggest an intermuddled complaint of the back and the sacroiliac. He says he does not recall his general practitioner explaining the difference between his lower back and sacroiliac joint and he did not think there was a distinction between the two because they are so close to each other. He thought his injury was in the lower back but he now thinks the issue could also be with his sacroiliac joint. This supports the pain being from the lower back.
8. Memories change over time and he is looking for a reason that his sacroiliac is problematic but that does not mean that it is from the employment, particularly ten months after the event. In one of his statement the applicant is talking about a consequential condition. No case is brought on a consequential condition and it is not supported by the applicant's own evidence. All you can look at is the treating material.
9. In Fox v Percy[3] it was said that further in recent years judges have become more aware of scientific research that casts doubt on the ability of judges or anyone else to tell truth from falsehood accurately on the basis of such appearances. Considerations such as these have encouraged judges both at trial and on appeal to limit their conclusions as far as possible on the basis of contemporary materials, objectively established facts and the apparent logic of events.
10. The respondent says you would only look at the contemporaneous material in the months after the applicant left work.
11. On 19 March 2020 no mention is made by the applicant in his statement of the sacroiliac joint and he says he continued to have back pain and the significant pain in his lower back radiated into his right leg, and the pain has not lessened since 28 January 2020.
12. Dr Noorzad's report of 3 June 2020 does not say anything about the sacroiliac, only back pain radiating to the buttocks and right leg, numbness and insomnia, and Dr Noorzad has not been told about it.
13. Dr van Gelder, neurosurgeon, on 18 May 2020 notes the applicant complains of ongoing back pain that radiates across his low back and down his ankles on both sides he has burning in his back at night. Pain seems to be centred around L4 and S3 in the lumbar spine with no neurological symptoms in the legs and no particular hip tenderness. There is no mention of the sacroiliac in a thorough examination and no history.
14. The respondent's submission is that the history given to or assumed by the doctors has not been given in a fair climate. The sacroiliac has not been referred to beforehand. The applicant's doctors have not addressed it and they have assumed something fundamental being that there were complaints essentially as soon as the applicant finishes work with the lower back, and it is a classic Paric[4] type submission. The applicant fails on his own case today.
15. Dr Nair sees the applicant on 15 September 2020 and he talks about his lumbar symptoms. Dr Nair, a specialist, notes restrictions on physical examination with no mention of the sacroiliac joint at this time. Mr Nasso, exercise physiologist, makes no mention of the sacroiliac on 18 September 2020 which you would expect.
16. Dr Parikh on 17 November 2020 records some tenderness over the sacroiliac joint bilaterally as well as tenderness over the lower L4/L5 region and paravertebrally. Under the heading Impression he says possible sacroiliac joint dysfunction and trochanteric bursitis. All of a sudden this now morphs into being a sacroiliac issue caused by employment but that is not what Dr Parikh is saying.
17. Dr Nair says on 12 May 2025 it is not unusual for the sacroiliac joint to be injured at the same time as the lower portion of the vertebral column including the lumbar spine, and this is what he has assumed.
18. If it was damaged at the time it would have been noted somewhere by the applicant or by one of those doctors. Associate Professor Woodgate forms a similar conclusion. In his report of

6 March 2023 he goes through a significant history and lists pain in a number of areas. By the time he sees him in January 2023 he just assumes that all of these symptoms are related to the initial period, the two years beforehand when he goes off work, and that is not an assumption that can be made good and this affects the weight you can put on their opinion. The complaint does not come on whilst working or weeks later, it comes on almost a year later. 19. Treating doctor's opinions carry some weight but they still have to be persuasive and they can only be persuasive if you are satisfied with the history they are given. They do not say even it came on ten months later it is still related to employment for some reason, but they do not say that, they assume that. 20. Associate Professor Neil gives a powerful opinion that he does not believes there is any pathology in the sacroiliac joint and the diagnosis is not related to a work injury on 31 January 2020. He gives this opinion in all his reports including his last report where he says the conditions are not work related, or consequential to the back injury, they are age related and pre-existing. There is another thesis here, although that does not have to be accepted as the treating doctors have to have given persuasive evidence in order to accept their opinion at all. 21. The respondent's submission is you cannot be satisfied on the Paric standard as these are fundamental assumptions relied on, that the applicant has pain at the time or soon after ceasing work. 22. On the issue of whether the reason for the surgery can be made good this principally comes from Associate Professor Woodgate's report of 26 April 2023. He comments on degeneration, supporting Associate Professor Neil, as there is obviously a degenerative process that could very well be the other reason which is urged by the respondent. 23. Associate Professor Woodgate says;

"You will recall his previous diagnostic injections were only into one part of the joint only. Should this injection give benefit, it would then be discussed the options of either prolotherapy or perhaps minimally invasive sacroiliac arthrodesis."[5]

1. Once again over the months and the years the doctors start to assume the injections were beneficial and so therefore there is a need for the surgery that is now proposed to take place. The doctors assume that because the pain is ongoing there remains an issue that needs to be corrected, but that is simply not the case.
2. Firstly the applicant tells Associate Professor Neil there was not a benefit and he found it extremely painful.[6] In his supplementary statement the applicant tells you the injections did not provide any relief, in fact worsened the pain in his lower back, and given the ineffectiveness he was subsequently recommended to undergo fusion surgery. Not only did the injections fail to alleviate pain but they increased his lower back pain making him reluctant to pursue further injection treatments.
3. Far from embracing the proposition put by Associate Professor Woodgate the applicant is also now hesitant of trying the next treatment proposed, the respondent submits.
4. In addition to Associate Professor Woodgate's and Associate Professor Neil's reports do not objectively establish the beneficial nature of the injections, and there is contemporaneous evidence suggesting the injections were not beneficial at all.
5. Dr Verma's opinion on 15 June 2022 says past injections have not helped the ongoing back and leg symptoms. Dr Parikh says the same thing. Dr Parikh says the applicant had multiple injections to bilateral sacroiliac joint as well as left hip and he found all these injections unhelpful in the long term.
6. Associate Professor Neil says the same thing, and the respondent says Dr Nair says the same thing.
7. The treating doctors no doubt for altruistic reasons believed what they were doing was helpful to the applicant but it was not. Perhaps the applicant was scared or nervous or may not have explained how unbeneficial these injections were for various reasons, but there is no mistake as he says this in his statement. He tells you over and over again the injections were not successful.
8. That is the very basis for Associate Professor Woodgate's opinion in his earlier report saying he wants to do this surgery. This backs up Dr Nair who wants to do it because they think the injections worked somewhat that a more significant form of treatment in that area will also work.
9. The bone scan of 2 December 2020 does not support there being ongoing issues in the sacroiliac. The further bone scan in November 2022 is referred to in Dr Rooney's report of

9 November 2022. He says the scans no longer demonstrate any increased uptake yet the applicant remains symptomatic. This is also Associate Professor Neil's opinion. 10. Associate Professor Woodgate on 6 March 2023 refers to the scan but he does not disagree with it. He notes there was no active sacroiliitis or seronegative arthropathy. He says separately the applicant also has precocious degeneration in both hips, worse on the left with left hip labral tear and possible pincer FAI and again his work has probably contributed, exacerbated and accelerated this. He does not refer to the scans showing significant uptake in the sacroiliac joint. 11. Associate Professor Woodgate's fundamental opinion is firstly that the applicant has had these problems straight away from January 2020 but there is evidence that brings that proposition into doubt. Secondly he says there is benefit from the injections and there is specific evidence where the applicant says he did not have that benefit. Thirdly he challenges Associate Professor Neil quite robustly when the bone scan seems to suggest there is no uptake there. Dr Rooney confirms it and Associate Professor Woodgate's later report does not traverse this. 12. Those things make a fundamental difference to the weight you can give to the treating doctors. The respondent's submission is the applicant cannot win on the case he has brought. 13. Associate Professor Neil's last report is very convincing, referring to two studies which have not been referred to or dealt with by the treating doctors, and although the report was provided yesterday there has been no application to adjourn or object to this report. You are left with one doctor giving pretty strident reasons why there should be caution and the surgery should not occur, particularly dealing with the lack of objective pathology in the scans and the uncontroversial proposition from the applicant that the injections did not work, and there is nothing in response, nothing to rebut that. 14. The cases of Charles Sturt University v Manning[7] and Ly v Jitt Offset Pty Ltd[8] essentially say you have to have good reasons to reject an expert in the absence of bias, you have to properly engage with the expert's opinion and give proper reasons as to why you would not accept one expert over the other. 15. In this case there are very good reasons why you would not accept the treating doctors and there are not so good reasons why you would not accept Associate Professor Neil as there is no real rebuttal to what he says in that final report.

1. The applicant's counsel apologised on the chronology and confirmed the respondent is correct about the date of Dr Nair's examination. The point nevertheless is that the treating experts being presented with the conundrum where the applicant complains of pain that had initially been thought to emanate from the lumbar spine but upon further examination of the radiology and so on that explanation did not appear to be viable.
2. One should proceed with caution in considering the applicant's assessment of his physiology. The experts had some difficulty in locating what the source of the pain was and ultimately they are confident that they did.
3. The injections were unhelpful in the long term. If they had provided long term resolution of symptoms he would not be looking for the surgery. The applicant is adamant that up to now they did him no good. The people who supervise the injections have concluded that they were helpful in the very short term.
4. The respondent's technical medical submissions are only useful to the extent that they are supported by an appropriate expert opinion, which in this case is from Associate Professor Neil who is of the opinion the applicant was not injured.

Did the applicant sustain a sacroiliac joint injury on 31 January 2020

1. The applicant must establish he sustained a sacroiliac joint injury on 31 January 2020 on the balance of probabilities.
2. In s 4(b) of the 1987 Act 'injury' includes a 'disease injury', "which means -

(i) a disease that is contracted by a worker in the course of employment but only if the employment was the main contributing factor to contracting the disease, and

(ii) the aggravation, acceleration, exacerbation or deterioration in the course of employment of any disease, but only if the employment was the main contributing factor to the aggravation, acceleration, exacerbation or deterioration of the disease..."

1. The respondent accepts the applicant sustained injury to his lower back on 31 January 2020 but disputes he sustained injury to his sacroiliac joints, relying on the opinion of Associate Professor Neil who diagnoses mechanical low back pain but not work-related injury of the sacroiliac joints.
2. I prefer and accept the applicant's evidence that he sustained a sacroiliac joint injury as a result of the nature of his work with the respondent for the following reasons.
3. The medical opinions of Dr Nair, Dr Rooney and A/P Woodgate support a finding that the applicant's sacroiliac condition is a disease contracted in the course of his employment with the respondent, and that the employment was the main contributing factor to contracting the disease.[9]
4. I accept the applicant's submission that the conclusions reached by these three treating specialists are the result of lengthy investigations and treatment, and supported by careful reasoning, made evident by the following;

(a) on 17 November 2020 Dr Parikh while managing the applicant's chronic lower back pain notes the applicant also has bilateral hip pain with some tenderness over the sacroiliac joint bilaterally;[10]

(b) the whole body scan on 2 December 2020 found the sacroiliac joint uptake appears within normal limits and the cause of the applicant's symptoms was not identified;

(c) by 30 March 2021 Dr Nair notes the applicant's pain seems to be more in the distribution of the left hip and sacroiliac joint and requests repeat imaging specifically looking at sacroiliac joint injury;

(d) MRI sacroiliac joints on 14 April 2021 concludes mild non-specific bilateral findings within the sacroiliac joints, presumed mechanical/degenerative in nature;

(e) the bone scan on 16 April 2021 concludes there is mild bilateral sacroiliac joint arthropathy;

(f) in May 2021 Dr Nair reports the bone scan and MRI are suggestive of sacroiliac joint dysfunction and he suggests sacroiliac blocks;

(g) on 13 May 2021 Dr Khan adds bilateral sacroiliac joint dysfunction to his certificates of capacity;

(h) on 4 August 2021 Dr Rooney examines the applicant, notes the imaging supports inflammation in both sacroiliac joints and recommends local anaesthetic and corticosteroid injection to the left sacroiliac joint, then the right side and then the left hip;

(i) Dr Linklater administered a left sacroiliac joint injection 28 August 2021. Associate Professor Woodgate notes on 6 March 2023 that unfortunately this was only into the true joint and not also into the fibrous/ligamentous part;[11]

(j) on 31 August 2021 Dr Nair notes the left sacroiliac symptoms improved to a degree for a period of time and right S1 joint injections will narrow down the pain generator;

(k) a right sacroiliac steroid injection was carried out by Dr Linklater on

7 October 2021;

(l) Dr Linklater administered a left hip joint steroid injection on 22 November 2021;

(m) as there was a good albeit temporary response from the left sacroiliac joint corticosteroid injection on 1 February 2022, Dr Nair suggests radiofrequency ablation and encourages a second opinion;

(n) the applicant remained troubled by left sacroiliac pathology on 7 June 2022;

(o) on 8 June 2022 Dr Nair carries out radiofrequency ablation of the left sacroiliac joint, and one month later his pelvic symptoms had improved although he continued to have features of discogenic lower back pain;

(p) Dr Nair reports to the insurer on 11 August 2022 the applicant first complained of symptoms in his left hip sometime in early 2020. When asked what his diagnosis is of the pathology impacting the worker's left hip, Dr Nair answers there is clinical and radiological evidence of left sacroiliac joint dysfunction;[12]

(q) lumbar diagnostic blocks (L5/S1 bilateral transforaminal blocks and epidural corticosteroid) were administered by Dr Nair on 26 October 2022;

(r) the whole body bone scan on 1 November 2022 found no evidence for active sacroiliitis or seronegative spondyloarthropathy;

(s) on 9 November 2022 Dr Rooney refers to the historical bone scan and history supporting bilateral sacroiliac joint issues with trochanteric bursitis, the 2022 scans no longer demonstrating any increased uptake, and seeks approval for the applicant to be reviewed and managed by Associate Professor Woodgate;

(t) Dr Nair reports the radiofrequency ablation had worn off by 6 December 2022 and as the applicant is troubled by left sacroiliac joint pain he requests a repeat bone scan;

(u) the pelvic X-ray on 23 March 2023 finds the sacroiliac joints show mild subarticular sclerosis and some blurring of the margins bilaterally without any discrete erosions or fusion;

(v) on 26 April 2023 Associate Professor Woodgate says; "the latest Xrays certainly suggest post-traumatic sacroiliac instability from his previous heavy work commitments",[13] and seeks approval for diagnostic injection to the left sacroiliac joint into both the true synovial and fibrous/ligamentous parts;

(w) on 11 May 2023 Dr Rooney agrees the left sacroiliac joint is an issue;

(x) on 10 July 2023 Dr Csillag administers CT S1 joint injection into the left sacroiliac joint, into both the upper ligamentous and lower synovial portions, which Associate Professor Woodgate reports took the applicant's pain from 6-7/10 to 0/10 for a number of hours during the local anaesthetic phase, definitive proof this is the major source of his symptoms;[14]

(y) on 5 November 2024 Dr Nair notes the applicant previously did have good albeit ephemeral relief from corticosteroid injections and radio frequency into the sacroiliac joint regions, and discusses the options including sacroiliac joint fusion, and

(z) on 3 December 2024 Dr Nair comments the S1 blocks improved symptoms dramatically for a few weeks and the pain generator is corroborated, options are repeat blocks two to three times a year and the definitive treatment would be sacroiliac fusion.

1. The experts relied on by the applicant each explain the basis for their opinions and set out their reasoning for diagnosing work-related sacroiliac joint injury.[15]
2. I do not accept the submission made by the respondent that the opinions of Dr Nair, Dr Rooney and Associate Professor Woodgate are based on an incorrect history or an incorrect assumption that the applicant complained of sacroiliac pain in early 2020.
3. The respondent submits there was no complaint made by the applicant of sacroiliac pain until Dr Nair refers to it in March 2021, and the absence of any contemporaneous record of the complaint must defeat the applicant's claim.
4. The contemporary documents show consistent complaints made by the applicant of lower back pain. The applicant's statement evidence on 19 March 2020 is that his back was in a great deal of pain in January 2020 radiating to his right leg.
5. Dr Noorzad's clinical records between January 2020 and April 2021 include complaints of lower back and buttock pain, back pain radiating to the right, and back pain and numbness in both legs. Dr Noorzad's report of 3 June 2020 refers to the applicant consulting him on

28 January 2020 for lower back pain radiating to his buttocks, and on 6 February 2020 the applicant was complaining of lower back pain radiating to his right leg. 6. The certificate of capacity issued by Dr Noorzad on 12 May 2020 includes the diagnosis of lower back pain radiating to his right buttock. 7. The applicant then began consulting specialists. On 18 May 2020 Dr van Gelder records the applicant's complaint of ongoing back pain radiating across his low back and down his ankles on both sides. 8. While Dr Parikh found bilateral hip pain with some tenderness over the sacroiliac joint bilaterally on his examination of the applicant on 17 November 2020, the applicant's treating specialists took further time investigating and identifying the source of this pain as set out above. 9. Dr Nair begins investigating sacroiliac joint pain in March 2021. Dr Khan's certificates of capacity include the diagnosis lower back pain until May 2021 when he includes bilateral sacroiliac joint dysfunction as an additional diagnosis. 10. The history of treatment and investigations explains the absence of a record of sacroiliac pain in the clinical records and reports prior to March 2021. The treating specialists' opinions are based on history provided by the applicant, their examination of him and the results of investigations. Any assumptions made that the source of the applicant's pain was only in the lower back was clarified as a result of their investigations. 11. While specialists should know the difference between lumbar spine pain and sacroiliac pain as the respondent submits, it is clear from the history of treatment and investigations that the pain source was difficult to identify. 12. I do not accept that any material that may have been put to the applicant's treating doctors represents an "unfair climate"[16] for the opinions they express in this case. 13. I agree generally with the respondent's submission regarding the fallibility of memory over time, however I accept the applicant's statement evidence that in January 2020 he understood the injury was to his lower back, and he was not able to distinguish between pain coming from the lower back or the sacroiliac joint. 14. I also accept the applicant's submission that caution should be taken in considering the applicant's assessment of his physiology, particularly in circumstances where three treating specialists had difficulty locating the sources of his pain. 15. The respondent submits that Associate Professor Neil's opinion that the applicant has not sustained an injury to his sacroiliac joint should be preferred. 16. A basis of Associate Professor Neil's opinion is that he cannot identify any verifiable pathology on clinical examination or on imaging to explain the applicant's current symptoms.[17] 17. The respondent submits the beneficial nature of the injections is not objectively established by Associate Professor Woodgate and Associate Professor Neil. 18. I do not agree the injections were unbeneficial based on the balance of the medical evidence. 19. Dr Nair refers to a previously good albeit temporary response from the left sacroiliac joint corticosteroid injection, and to previously good albeit ephemeral relief from corticosteroid injections and radio frequency into the sacroiliac joint regions. 20. In December 2024 Dr Nair says;

"The S1 blocks have improved symptoms dramatically for a few weeks. We have thus corroborated the pain generator. I've advised him that options would be repeat blocks that he could have two to three times a year. Definitive treatment would be sacroiliac fusion."[18]

1. Associate Professor Woodgate in August 2023 describes the injection 10 July 2023 as reducing the applicant's pain from 6-7/10 to 0/10 while the local anaesthetic was working, although later that night the pain rebounded as the local anaesthetic wore off and he had no delayed response to the steroid.
2. Associate Professor Woodgate states "this was a profound improvement with the local anaesthetic and certainly confirms the significant post-traumatic sacroiliac dysfunction/instability worse on the left."[19]
3. While the applicant consistently complains the injections were unhelpful it appears they assisted his treating specialists in identifying the source of his pain. The fact that the corticosteroid injections did not alleviate the applicant's pain also lends some support to the request for surgery.
4. The respondent submits Associate Professor Neil does not believe there is any pathology in the sacroiliac joint. I am not persuaded by this submission.
5. Associate Professor Neil initially noted tenderness on examination of the applicant's sacroiliac joints, and later comments that it would appear the applicant had scan evidence of bilateral mild inflammatory sacroiliitis which is now resolved, a disease unrelated to work.[20]
6. The balance of medical evidence is that there is some pathology in the sacroiliac joint.
7. Dr Rooney describes the bone scan of 1 November 2022 as no longer demonstrating any increased uptake as the respondent submits, however on 11 May 2023 Dr Rooney agrees that the sacroiliac joint is an issue.
8. While the pathology is not consistent, Dr Nair refers to the bone scan and MRI being suggestive of sacroiliac dysfunction and the positive effect of the radiofrequency ablation, Dr Rooney refers to imaging supporting inflammation in both sacroiliac joints and Associate Professor Woodgate describes improvement in pain from the injection on 10 July 2023.
9. Associate Professor Neil opines the applicant has age-related and pre-existing conditions including of the sacroiliac joints. There is no evidence however that appears to suggest the applicant has a pre-existing sacroiliac joint condition.
10. The applicant submits Associate Professor Neil does not provide any reasoned basis for the conclusion he reaches and in the absence of any further evidence I accept that submission.
11. I have not accepted the respondent's submission that there is a lack of objective pathology and the injections did not work. I am not persuaded by Associate Professor Neil's opinion given the investigations and conclusions reached by the three treating specialists discussed above.
12. I am persuaded by[21] and prefer the opinions of Dr Nair, Dr Rooney and Associate Professor Woodgate who diagnose sacroiliac joint dysfunction resulting from the applicant's employment with the respondent, following a consideration of the applicant's clinical history, their physical examination of him and the results of investigations.
13. The applicant has discharged his onus of establishing on the balance of probabilities that he sustained a sacroiliac joint injury on 31 January 2020 in the course of his employment and the employment was the main contributing factor to contracting the injury pursuant to s 4(b)(i) of the 1987 Act.

Is the applicant entitled to payment of the proposed sacroiliac arthrodesis (fusion) costs

1. A request for approval for left minimally invasive sacroiliac arthrodesis was made by Associate Professor Woodgate on 14 August 2023. Dr Nair makes a request for approval of left sacroiliac joint fusion on 3 December 2024.[22]
2. Section 60 of the 1987 Act provides for the payment by an employer of the cost of any reasonably necessary medical or related expenses received by a worker as the result of an injury in addition to any other compensation payable under the Act.
3. The legal test when determining whether proposed treatment is reasonably necessary as a result of a workplace injury was considered by Roche DP in Diab v NRMA Limited[23] at [86];

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

1. In Diab Roche DP cited the decision of Burke CCJ in Rose[24] with approval. While the essential question remains whether the treatment is reasonably necessary, the following are useful heads for consideration:

(a) the appropriateness of the particular treatment;

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

(c) the cost of the treatment;

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

(e) the acceptance by medical experts of the treatment as being appropriate and likely to be effective.[25]

1. Associate Professor Woodgate's opinion is the sacroiliac surgery is entirely reasonable. Dr Nair's opinion is the proposed procedure is reasonable and necessary. Associate Professor Neil does not believe minimally invasive sacroiliac arthrodesis on the left side is even necessary or rational.[26]
2. The weight of evidence establishes the proposed surgery is reasonably necessary.

1. In Associate Professor Neil's opinion the applicant does not satisfy the criteria for successful sacroiliac fusion as for it to work the pain needs to be localised to the sacroiliac joint with verifiable joint dysfunction. The applicant's pain in his view is diffuse and nonorganic and examination suggests a hyperpathic response to light touch.
2. Dr Nair and Associate Professor Woodgate conclude the pain generator has been identified.
3. Associate Professor Woodgate's opinion based on the positive clinical history, examination and diagnostic injection is the sacroiliac surgery is entirely reasonable.[27]
4. In Dr Nair's opinion the procedure will be predictable in terms of assuaging symptoms from the sacroiliac joint.
5. The evidence suggests the proposed surgery is appropriate treatment.

Availability of alternative treatment, and its potential effectiveness

1. Dr Nair's view is the applicant has exhausted all alternatives including multiple corticosteroid injections into the sacroiliac joints as well as extensive physical therapy. The options would be repeat blocks two to three times a year however definitive treatment would be sacroiliac fusion.
2. Associate Professor Neil's opinion is that no alternate or additional treatment will improve the applicant. Associate Professor Neil comments that the supporting literature for the outcome of sacroiliac arthrodesis is guarded in such a patient.
3. The applicant has received treatment since at least 2021 and the pain remains constant. The evidence supports that there are limited alternative treatments available, and two treating specialists are the view the proposed surgery is likely to be effective.

1. Associate Professor Woodgate's quotation for sacroiliac arthrodesis (fusion) - one side dated

17 February 2025 is in the amount of $8,592. The East Sydney Private Hospital fees dated 20 February 2025 are in the amount of $21,617. 2. Dr Nair comments the cost is approximately $40,000 including hospital stay and implants.[28] 3. Associate Professor Neil views the costs quoted as not cost effective. It includes sacroiliac arthrodesis fusion on one side but also includes spinal fusion anterior column, anterior direct lateral or posterior interbody.[29] 4. The cost of the proposed surgery would be at the appropriate SIRA gazetted rates.

Actual or potential effectiveness of the treatment

1. The surgery will not provide benefit or be effective in Associate Professor Neil's view and he refers to a Swedish study in The Lancet. Sacroiliac joint fusion appears to be a controversial operation although it does have a predictable outcome provided strict criteria are complied with. This is not the case here so that the proposed surgery is not reasonable and effective.
2. Dr Nair's view is that the literature is supportive of the procedure when the pain generator is narrowed, as is the case with the applicant. Associate Professor Woodgate refers to definitive proof that this is the major source of his symptoms. Both specialists conclude the procedure will be predictable in terms of assuaging symptoms from the sacroiliac joint.
3. This factor weighs in favour of the surgery being reasonably necessary.

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

1. As Dr Nair comments two independent and separate orthopaedic spinal surgeons have concluded the procedure will be predictable in terms of assuaging symptoms from the sacroiliac joint and Associate Professor Neil does not agree.
2. As discussed above I prefer the opinions of Dr Nair and Associate Professor Woodgate who accept the treatment is appropriate and likely to be effective.
3. A consideration of the factors as outlined in Diab support a finding that the proposed surgery is reasonably necessary.
4. For the respondent to be liable for the costs of and incidental to the proposed surgery the applicant must prove the accepted injury materially contributes to the need for the surgery.[30] The evidence is that the accepted sacroiliac injury materially contributes to the need for the proposed surgery.
5. I find the applicant is entitled to payment of the costs of the sacroiliac arthrodesis (fusion) proposed by Associate Professor Woodgate pursuant to s 60 of the 1987.

1. The applicant sustained a sacroiliac joint injury on 31 January 2020 in the course of his employment and the employment was the main contributing factor to contracting the injury pursuant to s 4(b)(i) of the 1987 Act.
2. The applicant is entitled to payment of the costs of the sacroiliac arthrodesis (fusion) proposed by Associate Professor Woodgate pursuant to s 60 of the 1987 Act.
3. There will be an order that the respondent pay the costs of and incidental to the sacroiliac arthrodesis (fusion) proposed by Associate Professor Woodgate at the appropriate SIRA gazetted rates.

[3] [2003] HCA 22; (2003) 214 CLR 118 at [31].

[4] Paric v John Holland Constructions Pty Ltd [1984] 2 NSWLR 505; Paric v John Holland (Constructions) Pty Ltd [1985] HCA 58.

[7] [2016] NSWWCCPD 10.

[8] [2021] NSWPICPD 2 at [92] - [93].

[9] ARD pages 46, 51 and 63, ALAD 1 page 3.

[15] Hancock v East Coast Timber Products Pty Ltd [2011] NSWCA 11; 80 NSWLR 43.

[16] Paric v John Holland (Constructions) Pty Ltd [1984] 2 NSWLR 505; Paric v John Holland (Constructions) Pty Ltd [1985] HCA 58; (1985) 62 ALR 85.

[21] Nguyen v Cosmopolitan Homes [2008] NSWCA 246.

[23] [2014] NSWWCCPD 72 (Diab).

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

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