RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00606
BRANCH OF SERVICE:  MARINE CORPS	 SEPARATION DATE:  20060115

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E-5, Motor Vehicle Operator, medically separated for “lumbar spondyloarthropathy” and Category II related “sacroiliac joint dysfunction,” rated 10% and 10%, respectively, with a combined disability rating of 20%. 

CI CONTENTION:  The applicant made no specific contention in his application.  The applicants complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  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 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 Veterans Affairs Schedule for Rating Disabilities (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 PEB - 20051019	VARD - 20060726	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar Spondyloarthropathy	5299-5237	10%	Intervertebral Disc Syndrome, Lumbar Spine with Left Lower Extremity Weakness	5243	20%	20060404	
Sacroiliac Joint Dysfunction	8599-5237	10%					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Low Back and Subsumed Category II Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI sustained a low back injury approximately 4 years prior to referral for MEB.  A lumbar spine X-ray showed bilateral widening, poor sacral side cortical definition, and erosive changes (L>R) of the sacroiliac (SI) joints. 
The radiologist opined that findings suggested bilateral active sacroiliitis (inflammation of the SI joint) and recommended dedicated SI joint X-rays or a bone scan if clinically indicated.  A lumbar spine magnetic resonance imaging (MRI) showed a mild circumferential disc bulge at L4-L5 and disproportionate spondyloarthropathy (vertebral joint disease) at L4-L5 and L5-S1.  A chiropractic clinic exam documented a normal gait with normal heel/toe walk.  The straight leg raise (SLR) test (assesses sciatic nerve root compression by a herniated disc) was positive on the left in the L5 dermatome (area of skin sensation from a single nerve from a single spinal cord nerve root) with pain reaching the ankle.  The Kemp’s test (assesses lumbar facet joints) was positive on the left.  Strength and deep tendon reflexes (DTRs) were normal with limited sensory loss in left L4 and L5 dermatomes.  The back ROM values were flexion of 70 (90 normal), extension of 25 (30), right lateral flexion of 40 (30), left lateral flexion of 40 (30), right rotation of 25 (30), and left rotation of 40 (30) degrees.  The assessment listed lumbar intervertebral disc degeneration.  A neurology encounter reported that an electrodiagnostic study (EMG/NCS) showed an L5 radiculopathy (irritation or injury of a nerve root) with an active denervating process.  Interventional pain management performed a facet block (injection of local anesthetic on nerves that supply the spine facet joints).  Chiropractic clinic exams revealed hypertonic para lumbar muscles and tenderness over the lower lumbar region and left posterior superior iliac spine.  The Yeoman test (assesses SI joint pathology) was positive on the left.  The diagnosis listed sacroiliac ligament sprain.  At a chiropractic clinic follow-up, the CI reported his overall condition had not improved.  He complained he still experienced tingling into the left leg to the big toe.  The pain limited back ROM values were flexion of 70 (90) and extension of 20 (30) degrees.  Extension and left lateral flexion caused pain into the left leg.  Rotation to end ROM caused a "popping” in his lower back which caused relief after an initial increase in pain.  The seated SLR was positive for tingling into the left posterolateral leg and sharper pain in the left buttock.  The assessment listed unspecified thoracic or lumbosacral neuritis or radiculitis and degeneration of lumbar or lumbosacral intervertebral disc.  A pain management exam revealed a tender left SI joint with a plan for a left SI joint injection.  A neurology physical exam revealed low back, paraspinal, and SI Joint tenderness.  Deep palpation of left SI joint reproduced local pain and spread down the leg.  A lumbar spine X-ray showed mild loss of the normal lumbar lordosis.  The radiologist opined it may be related to patient positioning or muscle spasm.  The NARSUM, 4 months before separation, recounted the history and interventions.  Following the initial injury, the CI improved with activity modification, medications, and physical therapy (PT).  Several months later, he exacerbated symptoms with addition of pain radiating into his left leg.  He experienced mild temporary relief with chiropractic manipulation.  Pain management performed lumbar epidural steroid injections, facet blocks, and SI joint injections without significant relief.  Neurosurgery determined the CI was not a surgical candidate.  Active medications were a muscle relaxant (Cyclobenzaprine) and a nonsteroidal anti-inflammatory drug (Meloxicam).  The physical exam documented a normal gait.  The back exam revealed normal alignment with tenderness over L4-5 and the SI joints.  Symptoms were exacerbated with left leg flexion, but there were no radicular symptoms.  Extremity ROM was full but no back ROM was documented.  Strength, sensation, and DTRs were normal and pathologic reflexes were absent.  The examiner recounted the findings from the lumbar spine X-ray and MRI.  The diagnoses listed lumbosacral spondyloarthropathy and SI joint dysfunction.  Pain management performed SI joint injections with local anesthetic and corticosteroids.  The neurology Review In Lieu Of (RILO) MEB Summary exam documented a normal native and stress gait.  The musculoskeletal exam showed left paraspinal local pain with radiation to buttocks with deep palpation.  The neurological exam revealed DTRs were normal and pathologic reflexes were absent.  Muscle strength, tone, and bulk were normal.  Proprioception was intact and there was a mild decrease in bilateral lower extremity vibratory sense in a stocking distribution.  The examiner recounted the findings of the electrodiagnostic study.  The diagnosis listed chronic low back pain.  The compensation and pension (C&P) exam recounted the history and interventions.  The CI complained of 4 years of lower lumbar and sacrum pain with radiation down the left leg.  The constant 9/10 pain was characterized as sharp, stabbing, aching, and squeezing.  
He reported associated symptoms of stiffness, weakness, and “my left side of my body goes numb.”  Pain was exacerbated by physical activity, prolonged standing, and prolonged lying and a muscle relaxant (Flexeril) and opioid (Oxycodone) provided little relief.  The CI reported that with pain he could function without medication and his condition did not cause incapacitation.  The physical exam documented a normal posture and gait without an assistive device for ambulation.  The spine exam revealed normal curvatures and symmetry of spinal motion.  The thoracolumbar spine exam revealed tenderness over the lower lumbar and sacral regions.  There was no muscle spasm or ankylosis.  The SLR test was positive on the left and there was evidence of radiating pain on movement down the left posterior leg.  The thoracolumbar ROM values were flexion of 45 (90), extension of 15 (30), right lateral flexion of 18 (30), left lateral flexion of 20 (30), right rotation of 30 (30), and left rotation of 30 (30) degrees.  Spine ROM was additionally limited by pain after repetitive use but not additionally limited by fatigue, weakness, lack of endurance, or incoordination.  Sensation and DTRs were normal.  There were signs of intervertebral disc syndrome with evidence of L5 motor weakness of left hip abduction (4/5) and S1 motor weakness of left knee flexion (4/5) and left plantar flexion (4/5).  The intervertebral disc syndrome did not cause any bowel dysfunction, bladder dysfunction, or erectile dysfunction.  The lumbar spine X-ray was negative.  The diagnosis listed intervertebral disc syndrome involving nerve root levels L4, L5, and S1.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5237 code (lumbosacral strain), plus 10% under an analogous 8520 code (mild incomplete paralysis of the sciatic nerve), for a total of 20%.  The listed Category II condition (SI joint dysfunction) was considered to contribute to the unfitting low back condition.  The VA assigned a 20% rating under the 5243 code (intervertebral disc syndrome) based on the VA C&P exam 3 months after separation.  The VA cited low back pain, radiation down left leg, radiating pain on movement, evidence of intervertebral disc syndrome with left hip and knee weakness, left SLR test positive, normal lumbar spine X-rays, normal posture, normal gait, lumbar spine tenderness, no muscle spasms, no ankylosis, ROM, ROM additionally limited by pain, and ROM not additionally limited by fatigue, weakness, lack of endurance, or incoordination.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  There were no back ROM values documented in the NARSUM.  The ROM values in the chiropractic exams were consistent with the 10% rating (flexion of greater than 60 degrees but not greater than 85 degrees; or a combined ROM of greater than 120 degrees but not greater than 235 degrees of the thoracolumbar spine).  The higher 20% rating would require (flexion of greater than 30 degrees but not greater than 60 degrees; or a combined ROM of not greater than 120 degrees of the thoracolumbar spine).  The ROM values in the C&P exam were consistent with the 20% rating.  While the proximate exams documented tenderness, there was no evidence of muscle spasm, guarding, abnormal spinal contour, or abnormal gait.  Other routes to a rating higher than the PEB’s 20% were considered, but there was no evidence of additional functional loss from repetitive use to warrant application of VASRD §4.45, and no evidence of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disc disease.  The Board considered whether a Service rating could be recommended under a peripheral nerve code, as conferred by the PEB, for the associated sciatic radiculopathy.  Serial exams documented the DTRs were normal and pathologic reflexes were absent.  There were left leg subjective complaints of radicular pain and objective findings of radiculopathy by electrodiagnostic testing, positive SLR tests, minor sensory disturbances, and circumscribed mild weakness by exam.  While the pain component of the radiculopathy is appropriately subsumed under the general spine rating criteria, members deliberated whether a sensory deficit or motor weakness impacted fitness to an extent that would justify rating.  

While a chiropractic and neurology exam documented mild left leg sensory deficits, the NARSUM and C&P exams noted normal sensation.  While the C&P exam documented 4/5 strength in the left L5 and S1 distribution, the balance of the exams noted normal strength.  The Board found there was no evidence that sensory deficits or motor weakness existed to any degree that could be described as functionally impairing.  The Board therefore concluded that additional disability rating was not justified on this basis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the low back condition plus 0% for the radiculopathy.

BOARD FINDINGS:  In the matter of the low back condition, the Board unanimously recommends a disability rating of 20%, coded 5299-5237 at 20% and 8599-8520 at 0% IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Lumbar Spondyloarthropathy 	5299-5237	20%	
Lumbar Spondyloarthropathy (Sciatic Radiculopathy)	8599-8520	0%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140115, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 11 Mar 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC