RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00351
BRANCH OF SERVICE:  Army	BOARD DATE:  20150616
Separation Date:  20051029

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Bradley Linebacker Crewmember) medically separated for low back condition.  The back could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  “Failed back syndrome secondary to spondylolysis and L5-S1 laminectomy and fusion” and “spondylolysis without spondylolisthesis,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic low back pain (LBP)” as unfitting, rated 20%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “I believe my lumbar spine was worse than the 20% percentage that the military gave me. My range of motion has gone down significantly over the years.  I have to wear a back brace, use a home tens system, and take continuous hydrocodone to help control symptoms.  The initial radiculopathy was fixed by in service surgery but has come [sic] back.  This significantly limits my ability to perform physical fitness and has a direct impact on my occupation.  I have had numerous incapacitating episodes over the years causing me to miss a lot of time from work.  I was also granted service connection for tinnitus on my initial VA rating decision and PTSD within 13 months following service.”

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:

Service IPEB – Dated 20050808	VA* - (~3 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5241	20%	Status Post Laminectomy and Fusion, L5-S1, Spondylosis	5241	20%	20060126	
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 2	
Combined:  20%	Combined:  30%	
*Derived from VA Rating Decision (VARD) dated 20060309 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic LBP Condition.  The CI sustained an injury on 16 January 2004which resulted in a brief loss of consciousness and back pain.  Radiographic and medical evaluations were essentially negative.  The CI was given Quarters for 3 days; however, 2 days later he presented with worsening back pain.  He was diagnosed with LBP and spasm.  He was treated conservatively and placed on a temporary profile.  The CI continued to complain of LBP during his MEDEVAC to Landstuhl for an appendectomy; however, a request for LBP evaluation was denied and he was returned to Theater.  A physical therapy evaluation after his recovery from surgery documented painful popping in the back during sit-ups and running.  The provider noted tenderness to palpation over the right sacroiliac joint with right greater than the left than left pain, antalgic gait, and bilateral hip pain with flexion and extension.  The CI was Medevac’d to Landstuhl for continued pain, numbness, and tingling that radiated down the right leg.  A lumbar spine X-ray showed a probable bilateral pars defect at L5.  The neurosurgeon documented reports of LBP with radiating pain down his right lower extremity and posterior knee.  There were physical exam findings of decreased range-of-motion (ROM) in his spine with normal motor and reflexes.  The magnetic resonance imaging (MRI) demonstrated L5-S1 bilateral facet degenerative changes, central disc protrusion at L4-5, and spondylosis.  The CI underwent a L4-S1 laminectomy and L5-S1 fusion on 25 August 2004.  The CT scan showed post-operative changes consistent with the L5-S1 laminectomy and fusion.  The CI underwent five lumbar spine X-rays from October 2004 through to August 2005 which consistently indicated lumbosacral spinal fusion without evidence of fracture, dislocation or hardware loosening.  The CI was given a permanent L3 profile for LBP (spondylolysis status post L5-S1 fusion).  The commander’s statement indicated that the CI was one of the most dependable and hardworking soldiers; however, since his injury he was unable to perform any duties required by his MOS.  The MEB narrative summary (NARSUM) examination, 5 months prior to separation, documented continued reports of constant LBP, paravertebral muscle spasm, and left leg pain. The MEB NARSUM physical exam findings are summarized in the chart below.  A repeat CT scan showed no change from the previous scan.  A repeat MRI demonstrated L4-5 disc dessication with a broad based disc bulge without herniation.  The VA Compensation and Pension (C&P) exam approximately 3 months after separation documented that the CI reported weakness in his back which limited his activity in being able to lift anything, stand for long periods, bend over or get in and out of chairs.  He had flares of sharp pain about five times a month that lasted a half to one day and would feel his back lock up with difficulty moving with pain rated at 8/10.  He also reported that walking was very difficult and he was incapacitated during the flares. The VA C&P physical exam findings are summarized in the chart below.

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

Thoracolumbar ROM
(Degrees)	NARSUM ~4.5 Mo. Pre-Sep
	VA C&P ~3 Mo. Post-Sep
	
Flexion (90 Normal)	Moderate/Severe (Can bring fingers ~10 cm below knees)	70 (40)*	
Extension (30)	--	20 (10)*	
R Lat Flexion (30)	--	20 (10)*	
L Lat Flexion (30)	--	20 (10)*	
R Rotation (30)	--	30	
L Rotation (30)	--	30	
Combined (240)	--	190	
Comment	Antalgic gait; stance position slightly bent forward at approximately 15 to 20 degrees with pain; moderately severe limitation in forward bend; lateral bend, hyperextension rotation all limited secondary to discomfort; paravertebral muscle spasm with motion;	*Deluca+ additional loss  of 30 degrees with flexion, 10 degrees with lateral bend right, left and extension with flare-ups; Antalgic gait; posture guarded; tenderness; motor/sensory intact	
§4.71a Rating	20%	20%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic LBP condition at 20%, coded as 5241 (Spinal Fusion).  The VA rated the status post laminectomy and fusion, L5-S1, spondylosis at 20%, coded 5241.  The “General Rating Formula for Diseases and Injuries of the Spine considers the CI’s pain symptoms with or without 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.”  The CI was given a permanent L3 profile for LBP (spondylolysis status post L5-S1 fusion).  The commander’s statement indicated that since the CI’s injury, he was unable to perform any duties required by his MOS.  The MEB examiner documented an antalgic gait and paravertebral muscle spasm.  The VA C&P examiner documented an antalgic gait and guarded posture and tenderness.  The Board agreed that the CI met the 20% rating criteria of “muscle spasm or guarding severe enough to result in an abnormal gait.”  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 chronic LBP 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 chronic LBP 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 20131201, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX 
President 
DoD Physical Disability Board of Review

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 XXXXXXXXXXXXXXXXXXXX, AR20150015849 (PD201400351)

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						     XXXXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA