Statement of Principles concerning THORACOLUMBAR SPONDYLOSIS (Reasonable Hypothesis) (No. 13 of 2023) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986. Dated 27 February 2023 The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of: Professor Terence Campbell AM Chairperson Contents 1 Name 2 Commencement 3 Authority 4 Repeal 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 thoracolumbar spondylosis (Reasonable Hypothesis) (No. 13 of 2023). 2 Commencement This instrument commences on 27 March 2023. 3 Authority This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986. 4 Repeal The Statement of Principles concerning thoracic spondylosis No. 64 of 2014 (Federal Register of Legislation No. F2014L00931) made under subsections 196B(2) and (8) of the VEA is repealed. The Statement of Principles concerning lumbar spondylosis No. 62 of 2014 (Federal Register of Legislation No. F2014L00933) made under subsections 196B(2) and (8) of the VEA is repealed. 5 Application This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004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 thoracolumbar spondylosis and death from thoracolumbar spondylosis. (2) This Statement of Principles applies to thoracolumbar spondylosis that has been diagnosed on the basis of: (a) clinical manifestations of local pain and stiffness, or symptoms and signs of thoracolumbar cord or thoracolumbar nerve root compression; and (b) imaging evidence of degenerative change, including disc space narrowing or osteophytes. Note: imaging evidence of degenerative change is defined in the Schedule 1 Dictionary. It will usually be the case that the date of the imaging evidence of degenerative change is after the date of clinical onset. (3) For the purposes of this Statement of Principles "thoracolumbar spondylosis" means a degenerative joint disorder affecting the thoracolumbar vertebrae or intervertebral discs including spondylosis at the thoracolumbar and lumbosacral junctions. (4) The definition of thoracolumbar spondylosis given at subsection (3) excludes diffuse idiopathic skeletal hyperostosis, Scheuermann disease and bulging of an intervertebral disc in the absence of other signs of disc degeneration. (5) Other commonly associated features of thoracolumbar spondylosis include facet joint arthritis, bone hypertrophy and spinal stenosis. (6) Thoracolumbar spondylosis attracts ICD‑10‑AM codes M47.14, M47.15, M47.16, M47.17, M47.24, M47.25, M47.26, M47.27, M47.84, M47.85, M47.86, M47.87, M47.94, M47.95, M47.96, M47.97 or M51.3, in applying this Statement of Principles the meaning of thoracolumbar spondylosis is that given in subsection (3). (7) In this Statement of Principles, the definition of "thoracolumbar spondylosis" is that given at subsection (3). (8) For subsection (6), 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), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4. Death from thoracolumbar spondylosis (9) For the purposes of this Statement of Principles, thoracolumbar spondylosis, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's thoracolumbar spondylosis. Note: terminal event is defined in the Schedule 1 – Dictionary. 8 Basis for determining the factors The Repatriation Medical Authority is of the view that there is sound medical-scientific evidence that indicates that thoracolumbar spondylosis and death from thoracolumbar spondylosis can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the MRCA. Note: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary. 9 Factors that must exist At least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting thoracolumbar spondylosis or death from thoracolumbar spondylosis with the circumstances of a person's relevant service: (1) being a prisoner of war before the clinical onset of thoracolumbar spondylosis; (2) having an inflammatory joint disease from the specified list of inflammatory joint diseases, in the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis; Note: specified list of inflammatory joint diseases is defined in the Schedule 1 - Dictionary. (3) having non-viral infection of the affected joint, resulting in inflammation within that joint, at least 6 months before the clinical onset of thoracolumbar spondylosis; (4) having an intra-articular fracture of the spine, at the level of, or adjacent to, the affected joint, at least 6 months before the clinical onset of thoracolumbar spondylosis; (5) having a spinal condition from the specified list of spinal conditions, affecting the thoracolumbar spine for at least the 6 months before the clinical onset of thoracolumbar spondylosis; Note: specified list of spinal conditions is defined in the Schedule 1 - Dictionary. (6) for lumbar spondylosis only, having a kyphotic abnormality or lordotic abnormality affecting the lumbar spine for at least the 6 months before the clinical onset of thoracolumbar spondylosis; Note: kyphotic abnormality and lordotic abnormality are defined in the Schedule 1 - Dictionary. (7) having undergone a spinal fusion, immediately above or below the affected joint, at least 6 months before the clinical onset of thoracolumbar spondylosis; Note: spinal fusion is defined in the Schedule 1 - Dictionary. (8) for lumbar spondylosis only, having leg length inequality for at least the 2 years before the clinical onset of thoracolumbar spondylosis; Note: leg length inequality is defined in the Schedule 1 - Dictionary. (9) having a depositional joint disease from the specified list of depositional joint diseases, in the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis; Note: specified list of depositional joint diseases is defined in the Schedule 1 – Dictionary. (10) having trauma to the thoracolumbar spine at least 6 months before the clinical onset of thoracolumbar spondylosis, and where the trauma to the thoracolumbar spine occurred within the 20 years before the clinical onset of thoracolumbar spondylosis; Note: trauma to the thoracolumbar spine is defined in the Schedule 1 - Dictionary. (11) having a penetrating injury to an intervertebral disc before the clinical onset of thoracolumbar spondylosis at the level of, or adjacent to, the intervertebral disc injury; Note: penetrating injury to an intervertebral disc is defined in the Schedule 1 - Dictionary. (12) having a thoracolumbar intervertebral disc prolapse at least 6 months before the clinical onset of thoracolumbar spondylosis at the level of the intervertebral disc prolapse; (13) lifting loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine to a cumulative total of at least 100,000 kilograms within any 10 year period before the clinical onset of thoracolumbar spondylosis; (14) carrying loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine to a cumulative total of at least 3,800 hours within any 10 year period before the clinical onset of thoracolumbar spondylosis; (15) for lumbar spondylosis only, flying in an engine powered aircraft as operational aircrew, for a cumulative total of at least 1,000 hours within the 25 years before the clinical onset of thoracolumbar spondylosis; (16) being obese for at least 10 years before the clinical onset of thoracolumbar spondylosis; Note: being obese is defined in the Schedule 1 – Dictionary. (17) having acromegaly involving the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis; Note: acromegaly is defined in the Schedule 1 - Dictionary. (18) having Paget's disease of bone involving the thoracolumbar spine before the clinical onset of thoracolumbar spondylosis; (19) being a prisoner of war before the clinical worsening of thoracolumbar spondylosis; (20) having an inflammatory joint disease from the specified list of inflammatory joint diseases, in the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis; Note: specified list of inflammatory joint diseases is defined in the Schedule 1 - Dictionary. (21) having non-viral infection of the affected joint, resulting in inflammation within that joint, at least 6 months before the clinical worsening of thoracolumbar spondylosis; (22) having an intra-articular fracture of the spine, at the level of, or adjacent to, the affected joint, at least 6 months before the clinical worsening of thoracolumbar spondylosis; (23) having a spinal condition from the specified list of spinal conditions, affecting the thoracolumbar spine for at least the 6 months before the clinical worsening of thoracolumbar spondylosis; Note: specified list of spinal conditions is defined in the Schedule 1 - Dictionary. (24) for lumbar spondylosis only, having a kyphotic abnormality or lordotic abnormality affecting the lumbar spine for at least the 6 months before the clinical worsening of thoracolumbar spondylosis; Note: kyphotic abnormality and lordotic abnormality are defined in the Schedule 1 - Dictionary. (25) having undergone a spinal fusion, immediately above or below the affected joint, at least 6 months before the clinical worsening of thoracolumbar spondylosis; Note: spinal fusion is defined in the Schedule 1 - Dictionary. (26) for lumbar spondylosis only, having leg length inequality for at least the 2 years before the clinical worsening of thoracolumbar spondylosis; Note: leg length inequality is defined in the Schedule 1 - Dictionary. (27) having a depositional joint disease from the specified list of depositional joint diseases, in the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis; Note: specified list of depositional joint diseases is defined in the Schedule 1 – Dictionary. (28) having trauma to the thoracolumbar spine at least 6 months before the clinical worsening of thoracolumbar spondylosis, and where the trauma to the thoracolumbar spine occurred within the 20 years before the clinical worsening of thoracolumbar spondylosis; Note: trauma to the thoracolumbar spine is defined in the Schedule 1 - Dictionary. (29) having a penetrating injury to an intervertebral disc before the clinical worsening of thoracolumbar spondylosis at the level of, or adjacent to, the intervertebral disc injury; Note: penetrating injury to an intervertebral disc is defined in the Schedule 1 - Dictionary. (30) having a thoracolumbar intervertebral disc prolapse at least 6 months before the clinical worsening of thoracolumbar spondylosis at the level of the intervertebral disc prolapse; (31) lifting loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine to a cumulative total of at least 100,000 kilograms within any 10 year period before the clinical worsening of thoracolumbar spondylosis; (32) carrying loads of at least 20 kilograms while bearing the weight through the thoracolumbar spine to a cumulative total of at least 3,800 hours within any 10 year period before the clinical worsening of thoracolumbar spondylosis; (33) for lumbar spondylosis only, flying in an engine powered aircraft as operational aircrew, for a cumulative total of at least 1,000 hours within the 25 years before the clinical worsening of thoracolumbar spondylosis; (34) being obese for at least 10 years before the clinical worsening of thoracolumbar spondylosis; Note: being obese is defined in the Schedule 1 – Dictionary. (35) having acromegaly involving the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis; Note: acromegaly is defined in the Schedule 1 - Dictionary. (36) having Paget's disease of bone involving the thoracolumbar spine before the clinical worsening of thoracolumbar spondylosis; (37) inability to obtain appropriate clinical management for thoracolumbar spondylosis. 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(19) to 9(37) apply only to material contribution to, or aggravation of, thoracolumbar spondylosis where the person's thoracolumbar spondylosis 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(2) 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: acromegaly means a chronic disease of adults resulting from excess production of growth hormone after closure of the epiphyses. being obese means having a Body Mass Index (BMI) of 30 or greater. Note: BMI is also defined in the Schedule 1 - Dictionary. BMI means W/H2 where: (a) W is the person's weight in kilograms; and (b) H is the person's height in metres. clinical onset means the point backwards in time from the first date of imaging confirming thoracolumbar spondylosis, to the date at which the symptoms of thoracolumbar spondylosis were persistently present, as assessed by a registered medical practitioner. imaging evidence of degenerative change means an image of the interior of a body obtained by medical techniques, including X-ray radiography or magnetic resonance imaging, showing prior degenerative change that is usually obtained at a date after the date of clinical onset of the disease. Note: clinical onset is defined in the Schedule 1 – Dictionary. kyphotic abnormality means abnormally increased dorsal convexity in the curvature of the lumbar vertebral column. leg length inequality means a clinically significant disparity of at least 2 centimetres in leg length, where the inequality remains uncorrected and involves the limb in daily use. Correction of the leg length inequality includes surgery or use of orthotic footwear with a raised heel. lordotic abnormality means abnormally increased dorsal concavity in the curvature of the lumbar vertebral column. MRCA means the Military Rehabilitation and Compensation Act 2004. penetrating injury to an intervertebral disc means piercing of an intervertebral disc by an object such as a bullet, shell fragment, knife or needle. relevant service means: (a) operational service under the VEA; (b) peacekeeping service under the VEA; (c) hazardous service under the VEA; (d) British nuclear test defence service under the VEA; (e) warlike service under the MRCA; or (f) non-warlike service under the MRCA. Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary. specified list of depositional joint diseases means: (a) alkaptonuria (also known as ochronosis); (b) calcium pyrophosphate dihydrate deposition disease (also known as pseudogout); (c) gout; (d) haemochromatosis; or (e) Wilson's disease. specified list of inflammatory joint diseases means: (a) ankylosing spondylitis; (b) arthritis associated with inflammatory bowel disease; (c) psoriatic arthritis; (d) reactive arthritis; or (e) rheumatoid arthritis. specified list of spinal conditions means: (a) deformity of a joint of a vertebra; (b) deformity of a vertebra; (c) scoliosis; or (d) spondylolisthesis. spinal fusion means surgery to permanently connect two or more adjacent vertebrae in the spine, eliminating motion between them. 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. thoracolumbar spondylosis—see subsection 7(3). trauma to the thoracolumbar spine means a discrete event involving the application of significant physical force to the thoracolumbar spine that causes: (a) damage to the thoracolumbar spine; and (b) the development within 24 hours of the event occurring, of symptoms and signs of pain and tenderness and either altered mobility or range of movement of the thoracolumbar spine. In the case of sustained unconsciousness or the masking of pain by analgesic medication, these symptoms and signs must appear on return to consciousness or the withdrawal of the analgesic medication; and (c) the persistence of these symptoms and signs for a period of at least 7 days following their onset, save for where medical intervention for the trauma to the thoracolumbar spine has occurred and that medical intervention involves one of the following: (i) immobilisation of the thoracolumbar spine by splinting, or similar external agent; (ii) injection of a corticosteroid or local anaesthetic into the thoracolumbar spine; or (iii) surgery to the thoracolumbar spine. VEA means the Veterans' Entitlements Act 1986.