Statement of Principles concerning SPONDYLOLISTHESIS AND SPONDYLOLYSIS (Balance of Probabilities) (No. 25 of 2017) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans' Entitlements Act 1986. Dated 24 February 2017 The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of: Professor Nicholas Saunders AO Chairperson Contents 1 Name 2 Commencement 3 Authority 4 Revocation 5 Application 6 Definitions 7 Kind of injury, disease or death to which this Statement of Principles relates 8 Basis for determining the factors 9 Factors that must exist 10 Relationship to service 11 Factors referring to an injury or disease covered by another Statement of Principles Schedule 1 - Dictionary 1 Definitions 1 Name This is the Statement of Principles concerning spondylolisthesis and spondylolysis (Balance of Probabilities) (No. 25 of 2017). 2 Commencement This instrument commences on 27 March 2017. 3 Authority This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986. 4 Revocation The Statement of Principles concerning spondylolisthesis and spondylolysis No. 60 of 2015 made under subsection 196B(3) of the VEA is revoked. 5 Application This instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies. 6 Definitions The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument. 7 Kind of injury, disease or death to which this Statement of Principles relates (1) This Statement of Principles is about spondylolisthesis and spondylolysis and death from spondylolisthesis and spondylolysis. Meaning of spondylolisthesis and spondylolysis (2) For the purposes of this Statement of Principles: (a) spondylolisthesis means forward displacement (anterolisthesis) or backward displacement (retrolisthesis) of one vertebra over the vertebra below; and (b) spondylolysis means a defect or fracture, unilateral or bilateral, involving the pars interarticularis of a vertebra. (3) While spondylolisthesis attracts ICD‑10‑AM code M43.1 or Q76.21 and spondylolysis attracts ICD‑10‑AM code M43.0 or Q76.22, in applying this Statement of Principles the meaning of spondylolisthesis and spondylolysis is that given in subsection (2). (4) For subsection (3), a reference to an ICD‑10‑AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD‑10‑AM), Ninth Edition, effective date of 1 July 2015, copyrighted by the Independent Hospital Pricing Authority, ISBN 978‑1‑76007‑020‑5. Death from spondylolisthesis or spondylolysis (5) For the purposes of this Statement of Principles, spondylolisthesis or spondylolysis, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's spondylolisthesis or spondylolysis. Note: terminal event is defined in the Schedule 1 – Dictionary. 8 Basis for determining the factors On the sound medical‑scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that spondylolisthesis or spondylolysis and death from spondylolisthesis or spondylolysis can be related to relevant service rendered by veterans or members of the Forces under the VEA, or members under the MRCA. Note: relevant service is defined in the Schedule 1 – Dictionary. 9 Factors that must exist At least one of the following factors must exist before it can be said that, on the balance of probabilities, spondylolisthesis or spondylolysis or death from spondylolisthesis or spondylolysis is connected with the circumstances of a person's relevant service: (1) experiencing a high impact trauma to the spine resulting in an acute fracture of the vertebral arch at the time of the clinical onset of spondylolisthesis or spondylolysis; (2) for spondylolisthesis only, experiencing a high impact trauma to the spine resulting in an acute fracture of the vertebral arch or dislocation of the involved vertebra within the one year before the clinical onset of spondylolisthesis; (3) for spondylolysis or spondylolytic spondylolisthesis in persons less than 25 years of age only, engaging in activities involving repetitive and forceful hyperextension, torsion or rotation against resistance of the spine for an average period of at least ten hours per week for the six months before the clinical onset of spondylolisthesis or spondylolysis; Note 1: spondylolytic spondylolisthesis is defined in the Schedule 1 - Dictionary. Note 2: Examples of activities involving repetitive and forceful hyperextension, torsion or rotation against resistance include gymnastics, pole vaulting, dancing, weightlifting, weight training, wrestling, judo, horse riding, swimming and playing football, tennis, volleyball, basketball, golf and cricket. (4) having undergone a spinal fusion of a segment of adjacent vertebrae before the clinical onset of spondylolisthesis or spondylolysis; Note: spinal fusion is defined in the Schedule 1 - Dictionary. (5) having undergone spinal surgery as specified at the level of the involved vertebra before the clinical onset of spondylolisthesis or spondylolysis; Note: spinal surgery as specified is defined in the Schedule 1 - Dictionary. (6) for degenerative spondylolisthesis of the lumbar or cervical spine only, having spondylosis at the level of the involved vertebra, before the clinical onset of spondylolisthesis; Note: degenerative spondylolisthesis is defined in the Schedule 1 - Dictionary. (7) having pathological damage to the affected vertebra at the time of the clinical onset of spondylolisthesis or spondylolysis; Note: pathological damage to the affected vertebra is defined in the Schedule 1 - Dictionary. (8) having rheumatoid arthritis involving the affected vertebra at the time of the clinical onset of spondylolisthesis; (9) for degenerative anterolisthesis only, being obese for the five years before the clinical onset of spondylolisthesis; Note: being obese and degenerative anterolisthesis is defined in the Schedule 1 - Dictionary. (10) experiencing a high impact trauma to the spine resulting in an acute fracture of the vertebral arch at the time of the clinical worsening of spondylolisthesis or spondylolysis; (11) for spondylolisthesis only, experiencing a high impact trauma to the spine resulting in an acute fracture of the vertebral arch or dislocation of the involved vertebra within the one year before the clinical worsening of spondylolisthesis; (12) for spondylolytic spondylolisthesis only, having trauma to affected region of the spine at the time of the clinical worsening of spondylolisthesis; Note: spondylolytic spondylolisthesis is defined in the Schedule 1 - Dictionary. (13) for spondylolysis or spondylolytic spondylolisthesis in persons less than 25 years of age only, engaging in activities involving repetitive and forceful hyperextension, torsion or rotation against resistance of the spine for an average period of at least ten hours per week for the six months before the clinical worsening of spondylolisthesis or spondylolysis; Note 1: spondylolytic spondylolisthesis is defined in the Schedule 1 - Dictionary. Note 2: Examples of activities involving repetitive and forceful hyperextension, torsion or rotation against resistance include gymnastics, pole vaulting, dancing, weightlifting, weight training, wrestling, judo, horse riding, swimming and playing football, tennis, volleyball, basketball, golf and cricket. (14) having undergone spinal surgery as specified at the level of the involved vertebra before the clinical worsening of spondylolisthesis or spondylolysis; Note: spinal surgery as specified is defined in the Schedule 1 - Dictionary. (15) for degenerative spondylolisthesis of the lumbar or cervical spine only, having spondylosis at the level of the involved vertebra, before the clinical worsening of spondylolisthesis; Note: degenerative spondylolisthesis is defined in the Schedule 1 - Dictionary. (16) having pathological damage to the affected vertebra at the time of the clinical worsening of spondylolisthesis or spondylolysis; Note: pathological damage to the affected vertebra is defined in the Schedule 1 - Dictionary. (17) having rheumatoid arthritis involving the affected vertebra at the time of the clinical worsening of spondylolisthesis; (18) for degenerative anterolisthesis only, being obese for the five years before the clinical worsening of spondylolisthesis; Note: being obese and degenerative anterolisthesis are defined in the Schedule 1 - Dictionary. (19) inability to obtain appropriate clinical management for spondylolisthesis or spondylolysis. 10 Relationship to service (1) The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person. (2) The factors set out in subsections 9(10) to 9(19) apply only to material contribution to, or aggravation of, spondylolisthesis or spondylolysis where the person's spondylolisthesis or spondylolysis was suffered or contracted before or during (but did not arise out of) the person's relevant service. 11 Factors referring to an injury or disease covered by another Statement of Principles In this Statement of Principles: (1) if a factor referred to in section 9 applies in relation to a person; and (2) that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(3) of the VEA; then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time. Schedule 1 - Dictionary Note: See Section 6 1 Definitions In this instrument: being obese means having a Body Mass Index (BMI) of 30 or greater. BMI means W/H2 where: W is the person's weight in kilograms; and H is the person's height in metres. degenerative anterolisthesis means forward displacement of one vertebra over the vertebra below due to segmental instability arising from osteoarthritis of the facet joints. degenerative spondylolisthesis means forward or backward displacement of one vertebra over the vertebra below due to segmental instability arising from osteoarthritis of the facet joints. MRCA means the Military Rehabilitation and Compensation Act 2004. pathological damage to the affected vertebra means a local or systemic disease process which significantly weakens or destroys the vertebral bone, including benign and malignant tumours, tuberculosis, osteomyelitis, osteoporosis and Paget's disease. relevant service means: (a) eligible war service (other than operational service) under the VEA; (b) defence service (other than hazardous service and British nuclear test defence service) under the VEA; or (c) peacetime service under the MRCA. Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary. spinal fusion means surgery to permanently connect two or more vertebrae in the spine, eliminating motion between them. spinal surgery as specified means surgery involving resection of the facet joints or parts of the vertebral arch (including laminectomy, laminotomy and facetectomy), or surgery to the spine that damages the integrity and stability of the spine. spondylolisthesis and spondylolysis—see subsection 7(2). spondylolytic spondylolisthesis means spondylolisthesis which develops where there is pre-existing spondylolysis of the affected vertebra. terminal event means the proximate or ultimate cause of death and includes the following: (a) pneumonia; (b) respiratory failure; (c) cardiac arrest; (d) circulatory failure; or (e) cessation of brain function. VEA means the Veterans' Entitlements Act 1986.