RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00209
BRANCH OF SERVICE: Army 		SEPARATION DATE:  20040410

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (COMBAT MEDIC) medically separated for a back condition.  The back could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “L4-5 discectomy w/recurrent bilateral lower extremity radiculopathy, EPTS, service aggravated,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded right shoulder crepitus and right knee pain as medically acceptable for PEB adjudication.  The Informal PEB adjudicated “chronic back pain,” and “right L5-S1 radiculopathy” as unfitting, rated 10% and 10% respectively, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI contends for her back and other conditions not identified by the MEB/PEB.  The applicant’s complete submission is at Exhibit A.  

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

IPEB - Dated 20040226	VA* - (~9 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5243	10%	Lumbo Sacral Diskectomy	5243	40%	20050207	
Right L5-S1 Radiculopathy	8520	10%	Radiculopathy, RLE	8520	20%	20050207	
Other MEB/PEB Conditions x 2 (Not In Scope)	Other x 2	
RATING:  20%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20050406 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Chronic Back Pain and Right L5-S1 Radiculopathy.  A civilian record dated 30 December 2002 recorded that the CI had low back pain (LBP) for 3 years with a recent flare.  She denied a specific injury and was noted have left lower extremity (LLE) weakness.  She was next seen on 15 January 2003 and reported that she had hit a deer the previous night and demolished her car.  On 28 May 2003, she was evaluated for a headache and, on the neurological examination, noted diminished sensation over the right lower leg and foot as well as weakness (implied for the right, but not explicitly stated).  An MRI the next day showed herniated discs at L4-5 and L5-S1 with the former impinging the nerve roots.  She was then seen in neurosurgery and reported increased pain after lifting several months earlier with a recent exacerbation.  She reported right > left weakness.  She had weakness, sensory changes, and diminished reflexes consistent with L4, L5, and S1 distributions and was thought to have a cauda equina syndrome (a serious loss of neurological function) and underwent L4-5 discectomy the next day.  Following surgery, she had a persistent foot drop as documented in a post-op follow-up on 18 June 2003.  On 28 July 2003, 2 months after surgery, the treating neurosurgeon noted that the CI had returned to running and was doing strengthening exercises.  Her dorsiflexion weakness (resulting in foot drop) had resolved and she was essentially free of numbness.  She was cleared to return to active duty in a letter from her surgeon to her primary care doctor.  The CI then entered active duty on 14 August 2003.  Four days later, on 18 August 2003, she was seen for a 3-day history of right knee pain without documented trauma.  She was then seen again on 25 August and multiple times in September 2003 for the knee pain.  On 25 September 2003, she was noted to have weakness of the right lower extremity (RLE), similar to what had been previously recorded before and after her surgery.  An MRI of the lumbar spine on 8 October 2003 was significant for soft tissue abnormalities and a lipoma at the end of the spinal cord.  The history of the prior surgery was not recorded on the MRI request.  Her physical examination was inconclusive.  A bone scan ordered on 14 October and done that day.  It showed uptake at L4-5, the site of the discectomy).  She also had stress changes of the feet, ankles, and knees.  In primary care on 16 October 2003, she reported that she had right foot weakness and also that she had been unable to run for the past 8 weeks (essentially since accession).  This is also the first record in evidence in which she reported the history of the back surgery.  The motor function of the RLE was reduced at 4/5, but the range-of-motion (ROM) of her back met or exceeded VA normal values.  She was referred to neurology and seen on 22 October 2003.  The history for the consult recorded that the CI had back surgery 3 years earlier (an error) and that her back pain had been present since she tripped and fell getting off of an airliner 8 weeks earlier.  This history was not previously recorded and the Board also noted that her complaints for the first month after accession were limited to her right knee.  The referral history also noted that the surgical scar was hidden by a tattoo.  At the neurology evaluation, the CI reported that her pain dated to 1997 when she fell from a 5-ton truck onto rocks.  She also reported that she had fallen getting off of an airplane in August and twisted her knee.  On examination, she was thought to have an S1 radiculopathy most likely related to the disc herniation and surgery.  A review of the MRI showed post-surgical changes without new herniation.  Continued physical therapy (PT) was recommended.  The CI was then seen in neurosurgery on 1 December 2003.  The ROM was reduced in flexion and is charted below.  The neurological examination and gait were normal.  Radiation of pain down both lower extremities was present.  Back pain with right > left lower extremity radiculopathy was diagnosed.  She was given a back brace based on later clinical notes.  At the MEB examination on 6 January 2004, the CI reported continued pain.  The examiner recorded that her back symptoms recurred in October 2003 and that there was “no injury.”  On examination, right foot and toe weakness were noted as well as a +/- decreased right ankle reflex.  The ROM was reduced.  It was identical to that obtained by the neurosurgeon, but the remainder of the examination differed in some areas making it less likely that the values were simply copied forward.  Electrodiagnostic studies on 8 January 2004 showed a right L5-S1 radiculopathy and a left L5 radiculopathy.  On examination, her gait was abnormal secondary to pain and the right ankle reflex absent.  Sensation was reduced on the right and 2 muscles in the RLE were reduced in strength, but others normal.  She was also issued a foot orthotic which helped her gait.  

The narrative summary (NARSUM) was dated 30 January 2004.  The CI stated that her back symptoms recurred following reenlistment, but denied “specific injury.”  She reported decreased sensation on the right foot and leg.  On examination (from the DD Form 2808), she had decreased right ankle reflex, diminished sensation over the right lateral leg, ankle, and foot as well as poor toe stand on the right side and decreased plantar flexion strength (not dorsiflexion).  Incapacitation was not recorded.  The final profile allowed her to walk at her own pace and distance.  An MRI on 9 March 2005, a month prior to separation, showed a stable lipoma (fatty tumor) and expected post-operative changes.  The CI was separated on 10 April 2004.  Following separation, she had both nerve root blocks (10 May 2004) and nerve root ablation (7 June 2004).  An MRI on 27 September 2004, 5 months after separation, showed fibrosis (scarring) at the site of the previous surgery which had not previously been documented.  A PT initial examination on 25 January 2005, 10 months after separation, recorded that her flexion was reduced at 30% of normal and extension at 50% of normal, but the normal range not recorded.  At the VA Compensation and Pension (C&P) examination performed on 7 February 2005, 10 months after separation, the CI reported that she woke up with LBP in May 2003 and had an emergency discectomy 2 weeks after onset.  She reported complete relief until October or November 2003 when she reinjured herself lifting up a 250 pound soldier.  The CI was on duty limitations for her knee in September and her back starting in October 2003.  She reported that she could not feel her right foot and that it was weak.  Incapacitation was not recorded.  She was unable to bend forward to tie her shoes.  On examination, she was very tender but had no spasm.  The ROM was very limited (below) by pain.  Muscle atrophy was present on the right as well as weakness.  Her reflexes were decreased on the left.  She had a severe limp, dragging the right foot.  The goniometric 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)	PCC ~6 Mo. Pre-Sep	Neurosurgery ~4 Mo. Pre-Sep	MEB ~3 Mo. Pre-Sep	VA C&P ~10 Mo. Post-Sep	
Flexion (90 Normal)	90	70	70	30	
Combined (240)	240	220	220	110	
Comment	Weakness w/o atrophy	Nml gait and neurological exam	Abnormal neurological eval.  Tenderness	Abn gait and neuro	
§4.71a Rating	0%	10%	10%	40%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the CI at 10% for chronic LBP, coded 5243 (intervertebral disc syndrome) and also at 10% for a right L5-S1 radiculopathy, coded 8520 (paralysis of the sciatic nerve), for a mild incomplete paralysis.  The VA used the same codes, but rated the back at 40% and the RLE radiculopathy at 20%, relying on the VA C&P done 10 months post-separation.  Both the PEB and VA determined that the back was an EPTS condition, but neither made a deduction for this and both conceded service aggravation.  The 28 July 2003 neurosurgical note, 2 weeks prior to re-enlistment, does not support a deduction for the EPTS conditions.  The Board then considered the ratings.  The ROM recorded by the VA supports a 40% rating.  However, multiple measurements prior to separation which were more proximate to separation support no more than a 10% rating.  The Board then considered the unfitting radiculopathy condition.  The neurological examination also showed minimal impairment prior to separation and was, in fact, noted by the neurosurgeon to be normal 4 months prior to separation.  The NARSUM documented that she had a poor toe stand on the right and diminished plantar flexion.  The VA examination, 10 months after separation, showed significant progression from the time in service.  The level of disability at separation supports a finding of mild impairment which is consistent with the 10% rating adjudicated by the PEB.  The Board considered the totality of evidence and found no route to a rating higher than that adjudicated by the PEB for either condition at the time of separation.  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 back pain or the radiculopathy 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 chronic back pain and right L5-S1 radiculopathy conditions and IAW VASRD §4.71a and §4.124a, 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 20131201, 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 XXXXXXXXXXXXXXXXXXXXXXXX, AR20160002075 (PD201400209)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA