RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXXX	   CASE:  PD-2014-00684
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060615

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Reserve (Active Guard Reserve) O3 (Infantry Officer) medically separated for cervical and lumbar spine disc disease.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Area of Concentration.  He was issued a permanent U3L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic neck and low back pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated “cervical disc disease associated with chronic neck pain”  and “ lumbar disc disease associated with lower back pain,” as unfitting, rated 0% and 0% respectively.  The CI made no appeals and was medically separated.  

CI CONTENTION:  He should have been given a higher rating for his conditions by the PEB.  Additionally, he contends he had a wrist and shoulder condition not considered by the PEB.  His 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 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:  

PDA Corr PEB - Dated 20060309	VA* - (~2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Disc Disease	5243	0%	Cervical Strain	5237	10%	20060801	
Lumbar Disc Disease	5243	0%	Degenerative Disease Lumbar Spine	5242	10%	20060801	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 12(Not In Scope)	
RATING:  0%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20070509 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY 

Neck Condition.  The service treatment record (STR) documents the CI complained of neck pain following a deployment to Afghanistan (2003).  A cervical spine X-ray was normal.  He was treated with chiropractic and pressure point manipulations with some benefit.  His neck symptoms persisted while he was deployed to Iraq (2004), but were manageable with Motrin.  Shortly after returning from Iraq, the CI sustained neck injuries during a parachute jump.  The cervical spine X-ray was normal.  A cervical spine magnetic resonance imaging (MRI) showed a small right central disc protrusion at C5/6 and a right lateral disc extrusion at C6/7 level creating moderate right lateral recess stenosis (narrowing), and impingement of the right exit foramen (opening).  Electrodiagnostic (EMG) studies showed evidence of moderate axonal (long nerve cell processes that transmit impulses) degeneration in the right C7 nerve root distribution and some nerve regeneration.  A neurosurgery evaluation documented a significant mass effect from a herniated disc on the C7 nerve root with associated weakness.  The surgeon opined that the best chance for a full recovery would be to decompress the nerve.  The plan was for a C6/7 anterior cervical decompression and fusion.  Pain management performed a diagnostic/therapeutic right C7 root sleeve injection with local anesthetic (bupivacaine) and steroid (Celestone).  The CI’s right shoulder and arm pain was 3/10 prior to, and 0/10 after, the procedure.  The physician opined that the CI’s symptoms were mediated by compression of the C7 nerve.  The neurosurgery follow-up reported the CI had been treated with physical therapy (PT) and a root sleeve injection.  His pain had resolved and he continued to improve.  The physical exam revealed improved strength of the right (4/5), compared to the left (5/5), triceps.  The Spurling’s test (assesses cervical nerve root compression by a herniated disc) was negative and he had excellent neck range-of-motion (ROM).  The surgeon recommended avoiding any axial loading in the form of wearing a helmet, wearing weights such as backpack, running on cement, or jumping out of planes, for at least 6 months.  The narrative summary (NARSUM) by orthopedic surgery, 6 months before separation, recounted the history and interventions.  The CI complained of chronic 4-5/10 posterior neck pain, which increased to 7/10 pain with activity.  Pain was exacerbated by activity (push-ups, running, cycling) and neck movement (especially rotation) and relieved with Motrin.  Pain no longer radiated to his arms and usually did not interfere with his sleep.  Right upper extremity weakness had improved.  The neck exam revealed near normal ROM with his chin reaching within one fingerbreadth of his chest.  The CI was sore with full rotation, especially to the left.  The cervical spine active ROM values, measured by goniometer/inclinometer, are listed in the chart.  The upper extremity motor exam revealed no visible atrophy or weakness, deep tendon reflexes (DTRs) were normal and equal, and pinprick sensation was intact.  The diagnosis listed chronic neck pain.  Physical medicine and rehabilitation (PM&R) performed a number of minimally invasive procedures to the cervical spine to reduce pain and inflammation.  These included epidural steroid injections, facet joint injections, pulsed radiofrequency medial branch blocks (radiofrequency ablation of medial branch nerves that supply facet joints), and BOTOX (Clostridium botulinum neurotoxin that blocks neuromuscular transmission) injections.  A cervical spine MRI showed a mild central disc protrusion at C4/5, a broad based disc bulge at C5/6, and a right paracentral disc herniation at C6/7.  There was no significant deformation of the cord or neural foraminal compromise.  

The Compensation and Pension (C&P) exam, 2 months after separation, recounted the history and interventions.  The CI complained of chronic 6/10 pain involving the entire neck.  Pain was characterized as aching and sharp with associated stiffness, weakness, and limitation of ROM.  Pain was exacerbated by activity and relieved by rest and Motrin.  While the pain did not cause incapacitation, it greatly limited physical activity and prolonged standing, sitting, or driving.  The physical exam revealed a normal gait and posture.  The spine exam revealed symmetry in appearance, symmetry of motion, and normal curvatures.  There were no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement.  The cervical spine exam revealed no evidence of muscle spasm, ankylosis (joint stiffening or immobility), tenderness, or radiating pain on movement.  The active ROM values are listed in the chart.  After repetitive use, the cervical spine function was additionally limited by pain, with an additional limit of the joint function by 0 degrees.  It was not additionally limited by fatigue, weakness, incoordination, or lack of endurance.  Upper extremity motor function, sensory function, and DTRs were normal.  The diagnosis listed intermittent cervical strain.

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

DOS 20060615
Cervical ROM
(Degrees)	MEB ~6 Mo. Pre-Sep
(20051228)	VA C&P ~2 Mo. Post-Sep
(20060801)	
Flex (45 Normal)	45 (62,60,58)	37	
Combined (340)	305	297	
Comment	Goniometer/Orthopedics	AO	
§4.71a Rating	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The informal PEB rated 0%, coded 5243 (intervertebral disc syndrome) for the neck condition.  The PEB cited injury from a parachute jump, chronic neck pain, cervical disc disease by MRI, EMG changes in the right C7 root distribution, non-compensable loss of ROM, and normal upper extremity strength (5/5).  The VA rating decision (VARD), citing the C&P exam months after separation, rated 10%, coded 5237 (cervical strain) for the neck condition.  The VARD cited injury from a parachute jump, cervical strain, chronic neck pain, cervical disc disease by MRI, radiculopathy of the right upper extremity, stiffness, weakness, decreased ROM, and pain with ROM.  Gait, spinal motion, spinal curvatures, and neurological exam were normal.  There was no evidence of radiating pain on movement, intervertebral disc syndrome, muscle spasm, tenderness, or ankylosis.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or VASRD §4.59 (painful motion).  The ROMs in the proximate exams (MEB and C&P) were consistent with the 10% rating (flexion of greater than 30 degrees but not greater than 40 degrees; or a combined ROM of greater than 170 degrees but not greater than 335 degrees of the cervical spine).  The higher 20% rating would require (flexion of greater than 15 degrees but not greater than 30 degrees, or a combined ROM of not greater than 170 degrees of the cervical spine).  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  The critical decision is whether or not there was significant motor weakness which would impact military occupation specific activities.  There was no evidence that motor weakness or sensory loss 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.  Other routes to a rating higher than a 10% were considered, but there was no evidence of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disk disease.  The C&P exam documented a normal gait with no evidence of cervical spinal muscle spasm.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the neck condition.

Back Condition.  The STR documents back pain following a deployment to Afghanistan (2003), which persisted while he was deployed to Iraq (2004).  Shortly after returning from Iraq, the CI sustained back injuries during a parachute jump.  The thoracic spine X-ray was normal.  A lumbar spine MRI showed mild degenerative disc disease (DDD), a small L2/3 disc bulge, and no central canal or neural foraminal stenosis.  The NARSUM recounted the history and interventions.  Ten days following the parachute mishap, the CI developed back pain and difficulty with erections.  He complained of chronic 2-3/10 low back pain which was exacerbated by activity (running).  He took no medications specifically for his low back.  The thoracolumbar spine active ROM values are listed in the chart.  Straight leg raise (SLR) tests (assess sciatic nerve root compression by a herniated disc) and Waddell’s signs (psychogenic, or nonorganic, manifestations of pain) were negative.  The lower extremity motor exam revealed no visible atrophy or weakness, DTRs were normal and equal, and pinprick sensation was intact.  The diagnosis listed chronic low back pain.  A lumbar spine epidural steroid injection was performed by PM&R.  The C&P exam recounted the history and interventions.  The CI complained of chronic 6/10 low back pain.  Pain was characterized as aching and squeezing with associated stiffness, difficulty moving, and limitation of ROM.  Pain was exacerbated by activity and relieved by rest and Motrin.  While the pain did not cause incapacitation, it limited physical activity, prolonged sitting, and prolonged driving.  The physical exam revealed a normal gait and posture, no assistive device for ambulation, and no foot signs of abnormal weight bearing.  The spine exam revealed symmetry in appearance, symmetry of motion, and normal curvatures.  There were no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement.  The thoracolumbar spine exam revealed no evidence of muscle spasm, ankylosis, tenderness, or radiating pain on movement.  The SLR tests were negative.  The active ROM values are listed in the chart.  After repetitive use, the thoracolumbar spine function was additionally limited by pain, with an additional limit of the joint function by 0 degrees.  It was not additionally limited by fatigue, weakness, incoordination, or lack of endurance.  Lower extremity motor function, sensory function, and DTRs were normal.  The diagnosis listed degenerative disease of the lumbar spine.

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

DOS 20060615
Thoracolumbar ROM
(Degrees)	MEB ~6 Mo. Pre-Sep
(20051228)	VA C&P ~2 Mo. Post-Sep
(20060801)	
Flexion (90 Normal)	70 (70,70,70)	90	
Combined (240)	220	240	
Comment	Goniometer/Orthopedics	AO	
§4.71a Rating	10%	0%	

The Board directed attention to its rating recommendation based on the above evidence.  The IPEB rated the back condition at 0%, coded 5243.  The PEB cited injury from a parachute jump, chronic lower back pain, lumbar disc disease by MRI, non-compensable loss of ROM, and normal lower extremity strength (5/5).  The VARD, citing the C&P exam, rated the back condition at 10%, coded 5242 (degenerative arthritis of the spine).  The VARD cited injury from a parachute jump, chronic back pain, lumbar disc disease by MRI, degenerative arthritis by X-ray, stiffness, decreased ROM, and pain with ROM.  There was a normal gait, no assistive device for ambulation, and no incapacitation.  Spinal motion, spinal curvatures, and neurological exam were normal.  There was no evidence of radiating pain on movement, intervertebral disc syndrome, muscle spasm, tenderness, or ankylosis.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or VASRD §4.59 (painful motion).  The limitation of motion in the C&P exam did not attain the minimum 10% rating based upon the general rating formula for diseases and injuries of the spine.  The ROM in the MEB exam was 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).  Other routes to a rating higher than a 10% were considered, but there was no evidence of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disk disease.  The C&P exam documented a normal gait with no evidence of thoracolumbar spinal muscle spasm.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the back 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 neck condition, the Board unanimously recommends a disability rating of 10%, coded 5243 IAW VASRD §4.71a.  In the matter of the back condition, the Board unanimously recommends a disability rating of 10%, coded 5243 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board 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	
Cervical Disc Disease	5243	10%	
Lumbar Disc Disease	5243	10%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140123 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 XXXXXXXXXXXXXXXXXXXXXXX, AR20160002379 (PD201400684)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA