Medicolegal Report

Patient Information: Name: Tama Nikora DOB: 14/08/1982 Sex: Male NHI: KLM4829 Address: 42 Rata Street, Riccarton, Christchurch 8041 Phone: 021 555 8392

Referring Party: Sarah Jenkins, Case Manager Accident Compensation Corporation (ACC) PO Box 242, Wellington 6140 Email: s.jenkins@acc.co.nz

Date of Examination: 18/10/2023

Purpose of Report: Assessment of ongoing lower back pain, functional impairment, and work capacity following a workplace lifting injury on 12/06/2023 (ACC Claim: AP9928374).

History:

• Presenting Complaint: 41yo male warehouse worker injured his lumbar spine on 12/06/2023 while lifting a 25 kg crate from floor height. Experienced immediate sharp lower back pain with radiation to the R posterior thigh. Currently reports persistent dull ache in the lower back (VAS 5/10), exacerbated by prolonged sitting (> 30 mins) and bending. Radicular symptoms have largely resolved. Currently working light duties 20 hrs/wk. Current meds: paracetamol (Panadol®) 1,000 mg PO QID PRN, ibuprofen (Nurofen®) 400 mg PO TID PRN.
• PMHx: Mild asthma. No prior history of lumbar spine pathology.
• PSHx: Appendicectomy (2005).
• FHx: Non-contributory.
• SHx: Lives with partner and two children. Non-smoker, social EtOH. Works full-time in warehousing and logistics (40 hrs/wk pre-injury).

Examination:

• General: Alert, cooperative, moves cautiously from sitting to standing. Normal gait.
• Vitals: BP 126/78 mmHg, HR 72 bpm, Temp 36.7 °C, BMI 26.4 kg/m².
• Lumbar Spine: Normal lordosis, no erythema or scarring. Tenderness on palpation over L4/L5 paraspinal muscles R > L. Flexion limited to fingertips to mid-shin due to pain. Extension reduced by 25%. Lateral flexion symmetric and full.
• Neurological (Lower Limbs): Straight leg raise negative bilaterally to 80 degrees. Tone normal. Power 5/5 throughout L2-S1 myotomes bilaterally. Reflexes symmetric (2+ patellar and Achilles). Sensation intact to light touch L1-S2 dermatomes.

Investigations:

• Lumbar Spine X-ray (15/06/2023): Normal vertebral alignment. Mild disc space narrowing at L4/L5. No acute fracture or spondylolisthesis.
• MRI Lumbar Spine (28/08/2023): Small right paracentral disc protrusion at L4/L5 contacting, but not compressing, the traversing R L5 nerve root. Mild facet joint arthropathy at L4/L5 and L5/S1.

Diagnosis: Acute-on-chronic L4/L5 disc protrusion with resolved right L5 radiculopathy, secondary to workplace lifting injury.

Opinion: Mr Nikora's clinical presentation and MRI findings are directly attributable to the lifting incident on 12/06/2023. While the MRI notes mild pre-existing degenerative changes (facet arthropathy and mild disc narrowing), these were asymptomatic prior to the event. The injury caused an acute L4/L5 disc protrusion. Prognosis is favourable for a full return to pre-injury duties over the next 6 to 8 weeks, given the resolution of radicular signs and steady functional improvement. No psychosocial yellow flags identified.

Recommendations:

• Continue structured physiotherapy focusing on core stabilisation and kinetic lifting techniques.
• Graduated return-to-work programme: increase hours to 30 hrs/wk for 2 weeks, then 40 hrs/wk, maintaining a 10 kg lifting restriction for the next 4 weeks.
• Cease regular ibuprofen; switch to celecoxib (Celebrex®) 200 mg PO OD PRN for flare-ups to reduce GI risk.
• GP review in 4 weeks to assess readiness for full clearance.

Conclusion: Mr Nikora sustained a work-related L4/L5 disc protrusion on 12/06/2023. Neurological deficits have resolved, leaving residual mechanical lower back pain. With ongoing physiotherapy and a graduated return-to-work plan, he is expected to achieve full recovery and return to unrestricted pre-injury employment within 6 to 8 weeks.

Signature: Dr Aravind Patel, MBChB, FRNZCGP General Practitioner Riccarton Medical Centre A. Patel