RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2013-01536
BRANCH OF SERVICE:  Army	BOARD DATE:  20150107
SEPARATION DATE:  20040920

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (63W/Vehicle Repair Mechanic) medically separated for syncope and lumbar spine conditions.  These conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty, although she was authorized to perform alternate physical fitness testing.  She was issued a permanent P3/L3 profile and referred for a Medical Evaluation Board (MEB).  The conditions, characterized as “neurocardiogenic vasodepressor syncope” and “chronic low back pain, traumatic disc disease with sciatica,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated the syncope and lumbar conditions as unfitting, rated 10% and 10%, respectively, citing criteria of the VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “I feel I was underrated for disability by the US Army and wish the Physical Disability Board of Review (PDBR) to review my case in order to determine if was properly rated for "Cardiogenic Syncope" (10%) and "Discogenic Disease and Fractured Disc at L5S 1" (10%).

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 syncope and lumbar conditions are addressed below; no other conditions are within the defined scope.  Any other condition or contention not requested in this application remains eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20040706	VA* (1 Mo. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Neurocardiogenic Syncope	8299-8210	10%	Syncope Cardiogenic	7099-7011	10%	20040823	
Chronic Low Back Pain	5237	10%	Discogenic Disease ... L5-S1	5243	10%	20040823	
Other x 0 (Not in Scope)	Other x 1 (Not in Scope)	20040823	
Combined:  20%	Combined:  20%	
*Derived from VA Rating Decision (VARD) dated 20041015 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:

Syncope Condition.  The earliest entries in the service treatment record (STR) for this condition are from September 2000 (4 years prior to separation) noting a 2-month history of recurrent dizziness, some episodes associated with transient syncope.  There are multiple STR entries over the ensuing years documenting recurrent episodes of syncope and an extensive evaluation.  An early tilt table evaluation was suggestive of vasodepressor syncope (deficit in automatic control of vascular constriction to maintain blood pressure during periods of demand).  Repeated Holter monitor evaluations (24 hour recordings of all heart beats) were normal (no arrhythmias explaining syncope); cardiac imaging (ECHO) was normal; and, an exercise stress test demonstrated a drop in blood pressure with maximum exertion, but overall good tolerance (METS 9.8).  Various medications were tried, and the frequency and severity of syncopal episodes decreased over time.  A cardiology entry in July 2003 (14 months prior to separation) noted that the CI “only has symptoms now when she sprints long distances.”  A cardiology entry in March 2004 (6 months prior to separation) documents “at least 4 more events in past 6 months, always with maximal exertion ... no events in the past month.”

The narrative summary (NARSUM) was prepared a month after the entry just described (same cardiologist), and repeated the same information.  The only documented limitation was “unpredictable” exertional syncope precluding retention.  At that time the CI was being treated with Milodrine (constricts vessels to prevent low blood pressure).  A VA Compensation and Pension (C&P) examination was conducted 23 August 2004 (a month prior to separation); and, that examiner documented a positive response to Milodrine in that the CI was experiencing pre-syncope with running, but “has not passed out completely as she has done previously.”  The VA examiner documented limitations with “running, sprinting ... [and] ... better with avoidance of these activities.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the syncopal condition analogously to 8210 for vasovagal nerve impairment, conferring its 10% rating for “moderate” deficit.  Since the vagus nerve reflex is involved in the pathophysiology of the type of syncope in this case, it is a reasonable choice; and, “moderate” is a fair characterization, given that the limitations were confined to significant exertion.  The VA arrived at a 10% rating under the analogous code 7011 (ventricular arrhythmias), citing criteria of the stress test measurement of METS (10% criterion is 7 – 10 METS) and the requirement for continuous medication.  Although the rating criteria are fairly applied to this case, the code itself is not a good clinical fit given the proven absence of arrhythmias as a cause for the syncope.

Other than the analogous 8210 and 7011 options just discussed, the only other code offered by the VASRD which might be analogously applied is 8999-8911 (petit mal epilepsy).  This code defaults to the VASRD §4.124a General Formula for Major and Minor Seizures; and, the self-limited exertional pre-syncopal episodes which the CI suffered might be fairly compared with the disability attendant to minor seizures.  The 20% criterion under 8911 (no higher ratings supported) is “at least 2 minor seizures in the last 6 months.”  The latter option was deliberated; but, members agreed that random uncontrollable seizures do not fairly equate with the pre-syncopal symptoms associated with strenuous exertion as evidenced in this case, which were fully controlled by reasonable regulation of activities.  It was therefore concluded that the rating derived from the PEB’s analogous 8210 coding choice was the best fit with the clinical features and disability in evidence.  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 of the syncope condition.

Lumbar Spine Condition.  The STR corroborates a history of low back pain dating to a vehicular accident during a deployment (to Jordan) in April 2003 (17 months prior to separation).  There are sporadic STR entries noting ongoing pain with occasional bilateral radiation, but no significant neurological findings; and, no STR evidence of gait disturbance, incapacitating episodes, or significant range-of-motion (ROM) limitation.  In June 2004, magnetic resonance imaging noted degenerative changes and mild disc disease at L5/S1.  There was no discussion of (or clinical indications for) surgery.  The orthopedic NARSUM (4 months prior to separation) documented “worsening low back pain” with bilateral sciatic pain and sensory symptoms; and, noted limitations with “long standing, long sitting, bending and lifting.”  The physical exam did not comment on gait or physical findings, but recorded ROM of flexion to 90 degrees (normal) and combined ROM of 235 (normal 240).  The VA C&P (a month prior to separation) examiner documented “discomfort once a week [rated 2/10, exacerbations to 9/10] ... with occasional radiation,” worsened with sit-ups and jogging.  The VA physical exam noted spasm and tenderness (there was an antalgic gait attributed to foot pain, not the lumbar condition), and normal strength and neurological findings.  The recorded ROM was flexion 75 degrees, extension 15, right lateral flexion 25, and left lateral flexion 20 (normal 30 for all planes other than flexion) without measurements for rotation.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating under 5237 (lumbosacral strain) and the VA’s 10% rating under 5243 (intervertebral disc syndrome) were both consistent with VASRD §4.71a criteria for the ROM in evidence.  There was no evidence of ratable peripheral nerve impairment or documentation of incapacitating episodes in this case which would provide for additional or higher rating.  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 of the lumbar spine condition.

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 syncope condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the lumbar 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 re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120918, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

				

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXX, AR20150007045 (PD201301536)

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						     
						         
CF: 
(  ) DoD PDBR
(  ) DVA