(b) lower back injury
103 On 17 December 2002 the plaintiff had an MRI lumbar spine scan resulting in the following report, accepted by the trial judge (Judgment, Day 1 at 71):
"At L4/5 the disc is normal in height and T2 signal intensity but there is a moderate left far lateral disc/osteophyte complex noted causing moderate encroachment on the foramen with possible irritation of the exiting left L4 root (axial slices 16-18, sagittal slice 3). Slight thickening of the ligamenta flava is also noted with a mild degree of left lateral recess narrowing in relation to the left L5 root (axial slice17)."
104 In May 2004 the plaintiff saw a Dr John Kellett, identified as a sports physician, who noted his history of low back pain and examined him for pain and disability in his back and legs. He concluded:
"I have asked Mr Bakavgas to have a repeat MRI scan of his lumbosacral spine and, if there is no significant deterioration in the disc protrusion, I would recommend a graduated physical retraining/work hardening program. The prospects for a good outcome and return to full time physical work for Mr Bakavgas are not good, based on the psychosocial factors probably more than the physical factors. Based on his past work history, it is probable that the aim should be for some physically less demanding form of work, at least for a considerable period of time to allow him to get back into a regular work habit."
105 In September 2005 the plaintiff saw Professor James Lance, a consultant neurologist. In relation to his past health Professor Lance noted:
"He told me that he fell several metres off a cherry-picker in 1996 and injured his back. He said that back pain persisted for about a year and he had to take six to eight months off work, because of it."
106 He also noted the plaintiff's description of "constant pain in the lower back but after a month or so of daily back pain may have 2-3 days free". He continued:
"He said that the pain radiates to his hips, buttocks and down the outer side of the calf and ankle.
He said that the underside of both big toes feel numb at times and his legs feel weak. The back pain is made worse by moving around during the day and at times, is made worse by bending. He said that it fluctuates in severity."
107 On examination Professor Lance noted:
"He was able to touch his toes and straight leg raising was full without discomfort. When the back was in the flexed position, he appeared to be tender over the lower lumbosacral spine and said that extension and rotation of the spine hurt.
Muscle tone, power and coordination were normal in the upper limbs. Muscle tone and power were normal in the lower limbs. Sensation was intact."
108 Professor Lance concluded:
"Mr Bakavgas has post-traumatic headaches, aggravated by his state of anxiety and depression. There is no indication of root irritation or compression in the lumbosacral area.
I did not assess his left shoulder which is the province of an orthopaedic surgeon and did not attempt to assess his dental problem."
109 In October 2005 the plaintiff saw Mr David Millons, a specialist surgeon. He noted a history of a slipped disc in 1996 whilst working as a storeman-packer, resulting in him being "off work for two months". The only treatment reported was "some physiotherapy". Mr Millons noted the MRI report of 17 December 2002 and commented, "Mr Bakavgas' symptoms are right sided". In his opinion he stated:
"There is a past history of a back injury in 1996 from which he, apparently, made a good recovery. He went along untroubled until the incident on 16/09/02. Something clearly happened to him that day which has turned the tide of things very much against him.
…
Mr Bakavgas claims to have problems with his lower back. There is evidence of some mild degenerative change in the lower lumbar region, a finding not infrequently seen in a man of his age.
His back is mildly stiff and irritable. There is no convincing evidence of any frank nerve root irritation or neurological deficit in either lower limb.
Mr Bakavgas has had some problems with his right knee. There does not appear to be a great deal untoward going on there. Radiologically, the knee has not turned up anything untoward.
Orthopaedically, apart from the left shoulder, there does not appear to be too much untoward going on which would preclude a return to work.
There do appear to be very considerable psychological problems on which I am not competent to comment."
110 The plaintiff was cross-examined about his back pain after the fall from the cherry-picker which in fact occurred in 1994 at Tcpt, 15/02/08, p 76. After being referred to the history taken by Professor Lance that the pain had persisted "for about a year" he was asked:
"Q. You certainly had back pain that persisted for a lot longer than about a year, didn't you?
A. No, but I was referring to after the accident.
Q. Excuse me. You certainly had back pain that persisted for longer than a year after your accident in 1994, didn't you?
A. Yes.
Q. It persisted right up until 2002; that's to say for eight years, didn't it?
A. Yes.
Q. It persisted in various degrees of severity, didn't it?
A. Yes.
Q. And when it was at its most severe you resorted to not just prescribed analgesic medication and anti-inflammatory medication, but also to intravenous amphetamines and cannabis?
A. Yes sir."
111 The accident occurred near the south coast town of Batemans Bay and the plaintiff was treated by Dr James Langley from the Batemans Bay Medical Centre. Dr Langley's notes through 2002 contain a number of references to low back pain and a painful right knee. On 10 January 2003 the following note appeared:
"Was doing well to [until?] involvement in struggle outside hotel on 4 January 03. Was protecting his 17 year old nephew. Prior to Saturday night - felt good - was almost fully recovered - no limping.
Mild low back pain persisted.
…
Now increased low back pain, right knee."
112 Dr Langley also noted that the plaintiff was keen to return to work but would be unfit until 27 January. He did not return to work, but was incarcerated shortly thereafter.
113 The only sustained period of work undertaken between the date of the accident and the date of trial appears to have been approximately three or four months working for a construction company in Canberra. That work appears to have been undertaken in the second half of 2003. He was asked if it was "pretty arduous work" and agreed it "wasn't easy": Tcpt, 13/02/08, p 17. He said that he had been mixing cement, erecting concrete formwork, and other work preparatory to laying concrete, including digging and using a compactor which required two men to lift it: Tcpt, pp 18-20. He gave evidence in chief that the work had been for three or four months and that he had to stop because he was "wearing down slowly from things that I had to lift, this and that, it wasn't a problem that I couldn't really do it, it was just painful while I was doing it and as I was going on and on it got worse": Tcpt, p 34. He appears to have seen a Dr Langsford at the Capital Medical Centre, until July 2004, although no records appear in the papers before this Court from Dr Langsford.
114 On 28 September 2006, some four years after the accident, the plaintiff was referred to a neurosurgeon, Dr Nadana Chandran. Dr Chandran was aware of the past history of a "slipped disc" in "1996" and the fact that the plaintiff was off work for a year at that time. In expressing an opinion, Dr Chandran stated:
"The history given by this man indicates that he developed symptoms after an incident at work in September, 2002.
While he had extensive symptoms and disability described, there was very little to find on clinical examination.
He had symptoms of back pain radiating into both legs but the scan has shown only a far lateral protrusion on the left which can explain the pain down the left leg but not the right leg.
Further conservative measures have been offered, with no indication for any surgical intervention.
On the basis of the history and the underlying disc protrusion, it was felt that he should not go back to any heavy physical work but consider retraining.
His present condition may be considered as arising from the injury that he described as having occurred in 2002 with symptoms going on since then."
115 The plaintiff underwent a medical assessment by Dr Brian Zeman in October 2006 at the Vocational Capacity Centre. Dr Zeman took a history which included the following:
"Using a diagram, he [the plaintiff] indicated areas of pain on both sides of the neck, left lower neck, between the shoulder blades, anterior sides of the lower chest, front of both knees, and low back. The worst pain was in the low back. It was constantly present although fluctuating in severity. The low back pain radiated down the back of the legs to the toes. His pain varied and he had difficulty stating what made it worse. Sometimes, he could do some things but on another occasion, it would be painful. He also could not say what relieved the pains. Sometimes, the tablets helped and other times not."
116 Dr Zeman appears from his report to have carried out a thorough physical examination. Dr Zeman's conclusions included the following:
"Although at various stages, he has reported neck, knee and shoulder pains, he has no significant clinical signs or functional restrictions, and no significant pathology on investigations.
Unrelated to the accident, he has:
- non-specific low back pain with investigation showing L4/5 disc prolapse and left nerve root compression that preceded the accident by 10 years.
- long standing behavioural and psychological problems with poor work history and a criminal record that included prior periodical detention, and a jail sentence of six months soon after the accident for unrelated events."
117 Dr Zeman had explained earlier in his summary of his examination:
"The circumstances of the accident in 2002 would not have caused or significantly exacerbated the lumbar spine condition that was pre-existent. On clinical examination and investigations, he has no significant pathology in the neck, left shoulder or right knee. Although he reports pain at various sites, the pain has been inconsistent and with no objective clinical signs and no reported consistent functional limitations."
118 The trial judge referred to the report of Dr Zeman (Judgment, Day 2, fifth page) but only after he had already made a finding in two parts. The first part (third page) was as follows:
"He certainly had a back problem over the years but his back problem appears to me to be one which was of itself somewhat transient. No doubt he had his good days and bad days and certainly there was some recourse to illicit drug abuse, as has been clearly identified in the evidence. But in one way, shape or form, it seems to me that the [plaintiff] was able to cope with that despite the problem that he had. Certainly there is some history of work, but only of a relatively short duration."
119 The second part of the finding was that the accident has "significantly exacerbated" his back problems and therefore had "a significant effect on his work capacity": Day 2, fourth page. His Honour made no finding as to the extent of the exacerbation or diminution in earning capacity. Nor did he make any finding as to whether the diminution continued unvaried throughout the period following the accident. The basis upon which the trial judge reached this conclusion is not entirely clear, in part because he dealt in his descriptive passages variably with the physical injuries and the psychological deficit. When he came to make a finding in relation to the back problem, he appears to have done so on two grounds, namely that the "mechanics of the accident itself" supported the likelihood of that occurring and the views of the treating practitioners: Judgment, Day 2, eighth page. That appears to have been largely in reliance upon the opinion of Dr Langley (referred to above) that the plaintiff "had lumbar disc disease which was at least aggravated by the injury on 16.09.2002": Report, 1 August 2003, p 3. Although Dr Langley thought it likely that he would have "ongoing back pain" and that heavy manual work "may not be possible", he made no attempt to distinguish the possible causes of that conclusion. He recommended referral to an orthopaedic surgeon, which occurred. Whether Dr Langley would have deferred to the views of the orthopaedic surgeon is not known. It appears that Dr Langley did not have an opportunity to read or comment upon Mr Millons' report. Furthermore, no medical expert appears to have expressed the view that the "mechanics of the accident" were more likely than not to have aggravated the back injury.
120 The appellant's case that it was not open on the medical evidence to be satisfied that the plaintiff had proved a causal connection between his back problems and the accident has force. Although the causal link might depend in part upon the evidence given by the plaintiff, his evidence might be expected to have limited weight given the nature of the issue, together with surrounding circumstances concerning his mental state and his use of illegal drugs as a form of medication, at least prior to the 2002 accident. It must also be noted that, on the plaintiff's case, he had not tested his back between 1994 and 2002 with any extended period of heavy labour, as for example on a construction site. The injury on 16 September 2002 occurred on his first day in that job.