RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	 CASE:  PD-2014-00694
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20061211	

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Security Forces, medically separated for “meralgia paresthetica,” with a disability rating of 10%.  

CI CONTENTION:  His condition continues to worsen and negatively impact his daily activities.  The applicant’s 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 Physical Evaluation Board (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 - 20061027	VARD - 20070910	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Meralgia Paresthetica	8729	10%	Meralgia Paresthetica Left Thigh	8729	10%	20070616	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Left Thigh Condition.  According to service treatment records (STR) and the MEB narrative summary (NARSUM), the left anterior thigh paresthesias (abnormal sensation, tingling, burning, prickling) began approximately 2 years prior to referral for Medical Evaluation Board (MEB).  The CI presented to the emergency department complaining of a 2-month history of intermittent left anterolateral thigh paresthesias.  Symptoms began while deployed, without a specific inciting event, and he had had no episodes in 2 days.  Paresthesias did not inhibit physical training or any other activity.  Serial lumbar spine X-rays revealed a normal lumbar spine with a possible right nephrolithiasis (kidney stone) and a computerized tomography (CT) was recommended. 
The abdominal and pelvic CT revealed no evidence of renal or urinary tract calculi (stones) or tiny bilateral fat-containing inguinal hernias (protrusion of organ or tissue through opening in surrounding walls).  A lumbar spine magnetic resonance imaging (MRI) showed an L5-S1 disc protrusion with associated small annular (disc fibrous exterior) tear.  There was no evidence of central canal or neural foraminal (nerve root opening) stenosis (narrowing).  An electrodiagnostic study (EMG/NCS) by neurology was interpreted as normal screening nerve conduction studies (NCS) of the right lower extremity.  There were mild signs of nerve/nerve root irritation at the femoral/L4 level.  The subjective symptoms were consistent with meralgia paresthetica (lateral femoral cutaneous nerve [LFCN] impingement).  The examiner recommended weight loss, loose fitting clothes, and to consider a trial of anticonvulsant or tricyclic medications.  In response to the neurology recommendations, family medicine started an anticonvulsant (Neurontin) for the meralgia paresthetica.  The CI reported some improvement in the left anterolateral thigh tingling, numbness, and pain.  Over serial encounters per the recommendations of neurology, family medicine titrated the Neurontin to the maximum recommended dose for off-label use for neuropathic pain.  If there was no improvement at the maximum dose, the plan was to convert to another anticonvulsant (Lyrica).  At a pain management consultation, the CI reported a yearlong history of chronic low back pain and intermittent tingling and numbness of the left thigh.  The thigh sensation was described as a “bugs crawling, tingling character.”  He complained that periodically he would wake up from a deep sleep with very intense pain in the left quadriceps.  The CI reported that his left leg would randomly go numb with prolonged lying or standing.  The lumbar pain was rated as 6/10 with medications, and 8/10 without.  Lower extremity pain was 3/10.  Pain was exacerbated by prolonged sitting, standing, walking, bending, squatting, lifting, pulling, and pushing and relieved by lying down, medications, and therapy.  He had previously taken Neurontin which helped to relieve some of the numbness.  Active medications were Lyrica and the nonsteroidal anti-inflammatory drug (NSAID) Celebrex.  The examiner recounted the findings of the MRI.  The physical exam documented the CI could walk on his heels and on his toes.  The back exam revealed tenderness in the left lower back (sacroiliac fossa, iliolumbar, and lumbosacral areas).  The Patrick test (assesses hip and sacroiliac joint pathology) produced pain on the side of his back and the straight leg raise (SLR) test (assesses sciatic nerve root compression by a herniated disc) was negative.  There were sensory changes noted in the anterolateral aspect of the left leg and reflexes were normal.  The diagnoses listed lumbago, meralgia paresthetica, L5-S1 disc bulging, and L5-S1 disc annular tear.  The NARSUM, 4 months before separation, recounted the history and interventions.  The CI had experienced sedation and confusion at the maximum dose of Neurontin with no substantial relief of pain.  He had been converted to Lyrica with increased profile restrictions prohibiting him from carrying or firing a weapon.  After 4 weeks on Lyrica, the CI did not experience any improvement in pain or sedation.  Active medications were Lyrica and Celebrex.  The physical exam documented a normal gait.  The back exam showed full range-of-motion (ROM) with SLR tests negative.  While the CI reported subjective tingling/pain in the proximal anterolateral thigh, the left leg exam revealed no pain with palpation and normal sensation.  The diagnosis listed left meralgia paresthetica.  A lumbar spine X-ray was unremarkable except for 3mm of retrolisthesis (posterior displacement of vertebra) of L5 over S1.  The Compensation and Pension (C&P) examination recounted the history and interventions.  The CI complained of intermittent left thigh numbness, tingling, and sharp pain.  He reported associated inability to differentiate between hot or cold on a portion of his left thigh.  The CI reported that numerous medications for pain, including pain patches, Neurontin, and Lyrica, had provided no relief.  No active medications were listed for this complaint.  Symptoms were exacerbated by activity (running, golfing, baseball), lifting, and load bearing.  The physical examination documented a normal posture and gait with no use of an ambulatory aid.  The spine examination revealed no abnormal curvatures (kyphosis, lordosis, scoliosis) or tenderness.  The lumbar spine ROM was full with no pain, weakness, fatigue, incoordination, or lack of endurance with repetitive movements.  Sensation (pain, touch, temperature, vibration) and deep tendon reflexes (DTRs) were intact.  The diagnoses listed left meralgia paresthetica and lumbar spine degenerative disc disease.
The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 8729 code (external cutaneous nerve of thigh neuralgia).  The VA assigned a 10% rating under the 8529 code (external cutaneous nerve of thigh complete or incomplete paralysis, severe) based on the VA C&P exam 6 months after separation.  The VA cited left anterior thigh constant numbness, intermittent pain, subjective tingling pain in anterolateral upper thigh, symptoms consistent with meralgia paresthetica, EMG showed mild nerve/nerve root irritation at femoral/L4 level, marginal symptom improvement despite increasing doses of Neurotin, normal gait, normal sensation in left thigh, intact pain, touch, and vibration sensation, decreased ability to determine temperature, and no evidence of muscle or motor function loss.  Meralgia paresthetica is a clinical syndrome of pain, dysesthesia (abnormal sensation), or both in the anterolateral thigh associated with compression of the LFCN.  The LFCN is susceptible to compression as it courses from the spine (lumbosacral plexus, through abdominal cavity, under the inguinal ligament, into subcutaneous tissue of thigh) to the thigh.  Neurologic symptoms are restricted to sensory changes as the LFCN is a pure sensory nerve and does not contain motor fibers.  The classic presentation is of subacute onset of burning pain, paresthesia, and hypesthesia (diminished sensation).  The neuralgia code (8729) is limited to a maximum of moderately severe incomplete paralysis (§4.124) which is a 0% rating.  As the LFCN is a pure sensory nerve, compression/impingement would not result in compromise of motor function.  In multiple exams, the neuralgia findings were characterized as numbness, tingling, and pain with no evidence of associated loss of reflexes, motor loss, or muscle atrophy.  Members agreed that findings did not approach severe to complete paralysis, consistent with a 10% rating under 8529 (external cutaneous nerve of thigh, paralysis of).  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 left thigh condition.

BOARD FINDINGS:  In the matter of the left thigh 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.  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 20140201, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00694.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings