RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  	CASE:  PD1300003
BRANCH OF SERVICE:  Army	BOARD DATE:  20130619
SEPARATION DATE:  20060430

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (15T10/UA60 Maintainer) medically separated for cervical and thoracolumbar spine conditions.  He injured his back in 2003; and was subsequently diagnosed with disk herniation and degenerative joint disease (DJD) in 2004.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent upper and lower extremity (U3/L3) profile and referred for a Medical Evaluation Board (MEB).  The neck condition, characterized as “degenerative joint disease – C5-6 disk herniation with diffuse pain syndrome and posterior cord syndrome” was forwarded to the Informal Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded four other conditions (history of shoulder pain, intermittent allergic rhinitis sinusitis/bronchitis, hyperlipidemia, and adjustment disorder) judged to meet retention standards.  The Informal PEB adjudicated “chronic cervical spine pain secondary to herniated nucleus pulposus C5/6 with radicular pain but no radiculopathy” as unfitting, rated 10%.  The remaining conditions were determined to be not unfitting and therefore not ratable.  The CI appealed to the Formal PEB and an Informal Reconsideration PEB re-adjudicated the case, at which time they added “thoracolumbar spine pain secondary to a broad based disc bulge at T3/4” as a separate and additional unfitting condition rated 10%.  Following this determination; the CI withdrew his demand for a formal hearing and was medically separated.

CI CONTENTION:  “Cervical spine injury that led to medical discharge led to CS-6 fusion in 2008. Chronic pain from back and neck injuries has led to ongoing pain management.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The ratings for the unfitting cervical and thoracolumbar back conditions are addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service Informal Reconsideration PEB – Dated 20060103	VA - (8 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Cervical Spine Pain Secondary Herniated Nucleus Pulposus C5/6 w/ Radicular Pain, but no Radiculopathy	5243	10%	DDD Cervical Spine	5243	20%*	20070109	
Thoracolumbar Spine Pain Secondary Broad Based Disk Bulge at T3/4 …Contacts the Cord	5243	10%	DDD Lumbar Spine	5243	10%	20070109	
Hx of Shoulder Pain	Not Unfitting	S/P Rt Shoulder Open Anterior-Inferior Capsular Shaft w/ Residual Scars	5299-5203	10%	20070109	
Intermittent Allergic Rhinitis Sinusitis/Bronchitis	Not Unfitting	No Corresponding VA Entry	
Hyperlipidemia	Not Unfitting	No Corresponding VA Entry	
Adjustment Disorder	Not Unfitting	Dysthymic Disorder	9433	10%	20061226	
No Additional MEB/PEB Entries	Other x 4	20070109	
Combined:  20%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20070424 (most proximate to date of separation [DOS]).   
* 20081217 VA Decision Review Officer Decision increased the Cervical Spine rating from 10% to 20% effective 20060501, increasing the combined rating to 40% effective the same date.

ANALYSIS SUMMARY:  The right handed CI injured his neck and back after jumping and catching a Frisbee during PT on 23 September 2003.  He felt his neck pop and felt diffuse back pain and spasms thereafter.  A magnetic resonance imaging exam performed that showed degenerative disk disease, and disk bulges in the cervical, thoracic, and lumbar spines.  Electromyography studies were normal, somatosensory evoked potentials studies were abnormal at the left median nerve.  The CI was referred for treatment and evaluation to physical therapy, physical medicine and rehabilitation, neurology, and neurosurgery.  He was not considered a surgical candidate at the time.  His profiled limitations were for neck/back pain, C5-6 herniated nucleus pulposus, L4-5 disc bulge and DJD, upper extremity (U3), and lower extremity (L3).  He was unable to fire or carry individual assigned weapon, unable to move with a fighting load at least two miles, unable to construct individual fighting position, unable to do 3-5 second rushes under direct and indirect fire.  His commander’s statement noted the CI was unable to perform his MOS duties and assigned administrative duties due to his medical conditions and profiled limitations.  The CI’s cervical spine condition worsened and on 15 October 2008, 2 years after separation, he had a C5-6 discectomy surgery of the neck.

Cervical Spine Condition.  At a neurosurgery evaluation on 3 August 2005, 9 months prior to separation, the CI minimal distress with full range-of-motion (ROM) testing summarized below, with normal strength, normal coordination, normal muscle strength, normal muscle bulk, normal coordination, normal gait, reflexes within normal limits, normal sensation to pinprick, vibration, and temperature.  The narrative summary (NARSUM) dictated on 9 December 2005, 5 months prior to separation, notes the CI suffered back pain described as cramping, sharp, and pulling pain 5-8 out of 10 exacerbated by prolonged standing, sitting, activity, wearing IBA and Kevlar.  He also complained of occasional numbness and tingling of hands, shock like sensation along spine, occasional erectile dysfunction, and no bowel or bladder symptoms.  Physical examination revealed normal motor strength, no muscle spasms were noted, normal deep tendon reflexes, normal sensation, normal coordination, normal gait, normal heel to toe, tandem, and backwards walk.  There was mild tenderness of spine, normal ROM noted in chart below.  He was unable to use Kevlar, interceptor body armor (IBA), run, ruck-march, construct a fighting position, or rush under fire.  At the VA Compensation and Pension (C&P) exam performed 8 months after separation, the CI reported occasional spasms, cramp-like, pulling, and shock-like 6-9 out of 10 pain of his back; and numbness and tingling sensation of his hands, and palmar surfaces of third, fourth and fifth digits, radiation of pain to arms and legs with IBA and Kevlar use.  Symptoms were exacerbated by walking, bending down, prolonged standing and sitting.  He occasionally used a cane for severe pain, denied sphincter control problems and erectile dysfunction.  Physical examination revealed no tenderness of cervical spine, slight decrease to light touch at the bilateral C6 dermatome, strength of the intrinsic muscles of both hands were slightly decreased to 4/5, normal coordination, normal deep tendon reflexes, normal gait, no paraspinal muscle tenderness.  Paraspinal muscle spasms were noted, and there was pain throughout ROM noted in chart below, lack of endurance after repetitive motion due to pain.  Cervical spine x-ray showed disc pathology, and straightening of the cervical spine.

The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Cervical ROM
(Degrees)	NeuroSurg ~9 Mo. Pre-Sep
(20050803)	AVN Med Clinic ~ 6 Mo. Pre-Sep
(20051108)	MEB ~ 5 Mo. Pre-Sep
(20051209)	VA C&P ~8 Mo. Post-Sep
(20070109)	
Flex (45 Normal)	Full	50 (45)	Full	45	
Extension (45)	Full	50 (45)	Full	45	
R Lat Flexion (45)	Full	50 (45)	Full	40	
L Lat Flexion (45)	Full	45	Full	40	
R Rotation (80)	Full	60 	Full	70	
L Rotation (80)	Full	60	Full	70	
Combined (340)	-	300	-	310	
Comment	Full ROM + minimal distress
Normal gait
Normal sensation
Normal strength
No spasms mentioned
	pain limitation at flexion, extension and L lateral flexion	Full ROM + minimal distress
Normal gait
No spasms mentioned	+Pain throughout ROM; +Lack of endurance; +Muscle spasms;
C6 decreased soft sensation;
Intrinsic m. of hand 4/5	
§4.71a Rating	10%	10%	10%	20%*	
*Changed from 10% by Decision Review Officer Decision on 17 December 2008 retroactive to date of separation.

The Board directs attention to its rating recommendation based on the above evidence.  Both the PEB and the VA used VASRD diagnostic code 5243 (Intervertebral disk syndrome) to evaluate the cervical spine condition for a 10% rating.  The Board did not find incapacitating episodes in the treatment record, for a higher rating under this code.  The Board also considered the VASRD general rating formula for diseases and injuries of the spine as directed by the VASRD as an alternate rating scheme.

The Board agreed that the CI did not meet the 20% rating criteria of forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees or, the combined ROM of the cervical spine not greater than 170 degrees; or, muscle spasm consistently present on multiple examinations, or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis, for a higher rating.  The Board noted the straightening of the cervical spine by radiological studies but there was absence of cervical paraspinal muscular spasm or loss of lordosis in most of the clinical examinations for a possible higher rating.  Thus, the Board could not attribute the straightening of the cervical spine to muscle spasm.  The Board considered whether an additional rating could be recommended under a peripheral nerve code for cervical radiculopathy.  Firm Board precedence requires a functional impairment tied to fitness to support a recommendation for addition of a peripheral nerve rating using VASRD codes for median nerve 8515 (paralysis), 8516 (neuritis), or 8517 (neuralgia) to disability in spine cases.  The sensory component in this case and slight motor weakness of the hands had no functional implications, such as dropping tools, per commander’s statement or CI’s assertions.  There was thus no evidence found of a separately ratable functional impairment (with fitness implications) from the residual radiculopathy; and, the Board could not support a recommendation for an additional Service disability rating on this basis.  Symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, are subsumed in the general rating formula for diseases and injuries of the spine using the VASRD 5243 code.

Thoracolumbar Spine Condition.  The NARSUM noted that that the lower back pain would occasionally radiate down the left leg to left ankle; and a shock like sensation along the spinal column, occurring almost daily.  Pain was ranged from 5 out of 10-8 out of 10 increasing with activity lasting most of the day.  Physical examination revealed normal strength, normal sensation to pinprick, vibration, and temperature, normal deep tendon reflexes, normal coordination, normal gait, and full ROM in minimal distress.  A separate ROM report performed on 8 November 2005 measured in degrees is noted in the chart below.  At the C&P exam the CI reported pain that occasionally radiates down left leg to the left ankle, and shock like sensation along the spinal column, radiating to both legs and arms at times.  Precipitated by walking, bending down, prolonged standing or sitting, could walk up to half mile, and occasionally used a cane for severe pain, no sphincter control problems, no erectile dysfunction.  The CI added that flare ups interfered with recreational activities, activities of daily living, and occupation.  He complained of lack of endurance with repetitive motion secondary to pain, and limitation of all overhead activities due to back pain.  Examination revealed slow and guarded ambulation, normal posture and gait with slight increase in lumbar lordosis, there was paraspinal muscle tenderness and spasm, positive straight leg raising test, pain throughout the thoracolumbar ROM, normal lower extremity motor and sensory examination.  Lumbar spine x-rays showed an essentially normal five view study, and normal thoracic spine.

The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)	AVN Med Clinic ~6 Mo. Pre-Sep
(20051108) 	MEB ~5 Mo. Pre-Sep
(20051209)	VA C&P ~8 Mo. Post-Sep
(20070109)	
Flexion (90 Normal)	80	Full	70	
Extension (30)	20	Full	30	
R Lat Flexion (30)	40 (30)	Full	30	
L Lat Flexion (30)	45 (30)	Full	30	
R Rotation (30)	50 (30)	Full	30	
L Rotation (30)	55 (30)	Full	30	
Combined (240)	220	-	220	
Comment	Flexion and extension limited by pain only.	Full ROM – minimal distress;
Spasm not mentioned;
Normal Gait.	Tenderness on palp L3-4; 
+Bilat straight leg raise;
+Pain throughout ROM; +Paraspinal muscle spasms;
+Lumbar lordosis;
Normal Gait	
§4.71a Rating	10%	10%	10%	

The Board directs attention to its rating recommendation based on the above evidence.  Both the PEB and the VA used VASRD diagnostic code 5243 (intervertebral disk syndrome) to evaluate the thoracolumbar spine condition for a 10% rating.  The Board found no incapacitating episodes in the treatment record, for a higher rating under the 5243.  The Board then considered the general rating formula for diseases and injuries of the spine as directed by the VASRD.  The Board agreed that the CI did not meet the higher 20% criteria of: forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined ROM of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm consistently noted on examination, or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.  The Board also considered whether an additional rating could be recommended under a peripheral nerve code for lumbar radiculopathy.  Firm Board precedence requires a functional impairment tied to fitness to support a recommendation for addition of a peripheral nerve rating to disability in spine cases.  The sensory component in this case had no functional implications, and no motor weakness was in evidence.  There was thus no evidence found of a separately ratable functional impairment (with fitness implications) from the radicular symptoms of radiating pain without sensory or motor loss; and, the Board cannot support a recommendation for an additional disability rating on this basis.  Symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, are subsumed in the general rating formula for diseases and injuries of the spine.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the cervical spine and thoracolumbar spine conditions.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the cervical spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the thoracolumbar spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Cervical Spine Pain Secondary to Herniated Nucleus Pulposus C5/6 w/ Radicular Pain, but no Radiculopathy	5243	10%	
Thoracolumbar Spine Pain Secondary Broad Based Disk Bulge at T3/4 that Contacts the Cord	5243	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20121219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(TAPD-ZB), 

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for AR20130019552 (PD201300003)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA