RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-00909
BRANCH OF SERVICE:  ARMY	BOARD DATE:  20141230
SEPARATION DATE:  20090615

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Food Service Specialist) medically separated for back and neck conditions.   The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent U3L3 profile and referred for a Medical Evaluation Board (MEB).  The back and neck conditions, characterized as  “chronic low back pain” and “cervical multilevel discogenic disease with radicular symptoms down right side to shoulder, to wrist and fingers causing chronic night shoulder pain” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (hemorrhoids and tinnitus) for PEB adjudication.  The Informal PEB adjudicated “intervertebral disc syndrome, lumbar spine” and “intervertebral disc syndrome cervical spine” as unfitting, rated 10% and 10% respectively with likely application of the VA 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 elaborated no specific contention in her application.

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:

Service IPEB – Dated 20090302	VA - (9 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Intervertebral Disc Syndrome, Lumbar Spine	5243	10%	Lumbar Central Disc Herniation	5237	10%	20080910	
Intervertebral Disc Syndrome, Cervical Spine	5243	10%	Cervical Discogenic Disease with History of Right Upper Extremity Radiculopathy	5237	10%	20080910	
Other x 2 (Not in Scope)	Other x 3	20080910	
Combined:  20%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20090827 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Back Condition.  The narrative summary (NARSUM) notes the CI first reported low back pain (LBP) in July 2007 following injury while lifting equipment.  Notes in the service treatment record (STR) indicated the LBP persisted with development of lower extremity (LE) radiating pain, occasionally noted to be bilateral, but primarily right (RLE) radicular symptoms to the ankle.  Lumbar spine magnetic resonance imaging (MRI) on 10 October 2007 showed degenerative disc disease (DDD), without lumbar spinal stenosis or nerve encroachment.  At an orthopedic evaluation on 17 October 2007 lumbar X-rays noted reversal of the lumbar curve.  The exam noted no neurological abnormalities and the examiner indicated the MRI did not show nerve root impingement; no surgery was recommended.  Orthopedic follow-up on 4 December 2007 noted back and RLE pain with full flexion and extension and painful ROM, with an otherwise normal exam (no abnormal reflexes noted) and the CI was put on quarters for 48 hours due to medication side effects.  The CI was treated with lumbar traction, which worsened the LBP severely and the CI was brought to the emergency room by the therapists for care, but later continued with traction treatments.  The CI was evaluated by physical medicine and electromyography/nerve conduction studies (EMG/NCS) of the bilateral upper extremities (UE) and lower extremities on 14 March 2008 were normal.  The CI was referred to neurosurgery on 28 April 2008, primarily for neck symptoms as discussed further below. The CI also reported LBP with numbness of the bilateral feet noted, with no mention of bowel or bladder problems.  On examination there was normal LE strength and sensation, with hyperactive but symmetrical knee reflexes noted (3+/4) without clonus.  Impaired balance was also observed.  The examiner commented that the RLE symptoms may be related to cervical compression, and noted that there was no significant lumbar spine nerve compression to explain foot numbness.  The neurosurgeon recommended the low back be treated non-operatively.  The CI pursued acupuncture and alternative medicine treatments with some improvement in symptoms, but exacerbations of LBP continued.

At the MEB examination on 22 December 2008, approximately 6 months prior to separation, the CI reported constant LBP with radiation down the right leg with activity.  The MEB physical exam noted normal gait, stance, and balance.  There was tenderness to palpation (TTP) of the lumbar spine without muscle spasm and ROM was normal with painful motion.  Lower extremity reflexes were reported as normal, strength noted slight decrease of right foot strength and 4/5 strength of the great toe extension.  No objective sensory deficits were noted.  At an earlier physical therapy visit to measure ROM for the MEB on 3 October 2008 the CI reported pain in the back.  ROM of the thoracolumbar (TL) spine was flexion of 38 degrees (normal 90 degrees), and combined ROM of 175 degrees (normal 240 degrees), with guarding and an abnormal gait noted.  The PEB requested that ROM be re-evaluated due to the discrepancy between the PT and VA ROM (cited on the DD Form 2808 Report of Medical Examination) performed a month apart.  At the repeat PT evaluation on 26 February 2009, approximately 4 months prior to separation, the CI reported to the examiner that “overall today is a good day and her back feels okay - yesterday was a bad day.”  TL ROM was flexion of 90 degrees and combined ROM of 235 degrees, with painful motion noted.

At the VA Compensation and Pension (C&P) examination on 10 September 2008, performed 9 months prior to separation, the CI reported pain graded 4/10 when aggravated by activity.  On examination gait was normal.  There was TTP of the lumbar muscles.  Lumbar flexion and combined ROM was full, without muscle spasm.  No increased loss of ROM was noted with repetitive use and painful ROM was not noted.  Straight leg raise testing was negative for radicular symptoms, but increased LBP.  Lower extremity strength, sensation, and reflexes were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5243 (intervertebral disc syndrome) and the VA rated it 10%, coded 5237 (lumbosacral strain).  The Board agreed that the evidence in record supports the 10% rating at separation according to current VASRD spine rating rules in effect at the time, with consideration of §4.59 (painful motion).  There was evidence of a single incapacitating episode of 48 hours due to the low back condition in the year before separation, which is insufficient to provide a higher rating than 10%.  The Board next considered if there was evidence of a functionally impairing radiculopathy due to the low back condition to provide additional rating.  The lumbar MRI did not show any lumbar spinal stenosis or nerve impingement, EMG/NCS were negative, and the neurosurgeon thought the RLE symptoms may have been related to the neck condition rather than the lower back.  Therefore, the Board agreed there was insufficient evidence to recommend additional rating for peripheral nerve impairment due to the low back condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication for the lumbar spine condition.

Neck Condition.  The NARSUM noted that in November 2007, a few months after injuring her low back the CI developed pain in her neck and shoulders, especially on the right.  Notes in the STR indicated the CI reported right shoulder pain with radiation to the right hand on 19 November 2007.  Shoulder examination was normal with normal strength, sensation, and reflexes in the upper extremities (UE).  At a physical therapy (PT) evaluation on 28 November 2007 the CI reported RUE pain into the thumb, with occasional little finger numbness and difficulty holding objects.  Examination noted mild weakness of shoulder movement bilaterally and weak grip strength on the right, without objective RUE sensory deficit and the CI was referred for cervical MRI.  Around the time that the CI first sought help for neck pain she reported several episodes of loss of bladder control and was referred to urology and treated for stress urinary incontinence.  Cervical spine MRI performed on7 January 2008 showed DDD and arthritis with borderline cervical spinal stenosis and bilateral neuroforaminal narrowing, worse on the right at C5-C6.  The CI engaged in PT with modest improvement in her neck pain.  A PT visit on 11 February 2008 noted moderate neck pain (4-5/10), mild weakness of all RUE movements, and mild weak left grip strength.  As noted above in the lumbar spine discussion EMG/NCS of the bilateral UE and LE 14 March 2008 was normal.  At an orthopedic evaluation for the neck on 3 April 2008 the CI reported neck pain that radiated to the top of her right hand and often dropping things and that the neck and RUE pain were equal concerns.  The examiner indicated “no bowel or bladder incontinence.”  The examination noted TTP and painful cervical ROM, subjective decreased sensation and decreased right grip strength, but there was no muscle atrophy and reflexes were normal.  The CI was referred to an orthopedic specialist with cervical expertise on 9 April 2008 who noted cervical stenosis and radiculitis and referred the CI to pain management for possible epidural steroid injection and to a neurosurgeon for a second opinion.  At the neurosurgical evaluation on 28 April 2008 the CI reported moderate neck and back pain with numbness and tingling of the hands and feet, progressive difficulty with handwriting, weakness in her hands, and dropping objects, difficulty navigating stairs, but no gait problems, with no mention of bowel or bladder problems.  The neurosurgeon noted that there was no evidence of lumbar radiculopathy clinically or on the MRI.  Examination noted mild RUE weakness and mild, limited LUE weakness, normal sensation bilaterally, and equal reflexes bilaterally without clonus, and impaired balance was observed.  The assessment was that the CI had myelopathic symptoms due to the cervical cord compression and the examiner opined that the right foot symptoms may be related as well.  Repeat MRI was performed that afternoon and the neurosurgeon indicated it showed congenital spinal stenosis with cord compression at C4-C7 and surgery was recommended.  The CI deferred surgery and said she would further consider when her family visited from out of the country.  She was noted to not take pain medications because she preferred not to and participated in acupuncture and other alternative medicine treatments.

At an occupational therapy visit on 7 May 2005 the CI was evaluated for functional limitations.  The CI noted difficulty with activities of daily living related to her low back pain, with no report of difficulty due to UE weakness or numbness.  The neck pain and numbness and “some weakness” of the right arm and leg continued, but at visits on 18 December 2008 and 15 January 2009 the CI noted neck pain was stable, and indicated she could function, and preferred to continue to defer surgery.

At the MEB examination, approximately 6 months prior to separation, the CI reported chronic neck and RUE pain.  The MEB physical examination noted the CI was right hand dominant.  On examination the CI had spinal TTP at C7 with full neck ROM and no signs of cervical weakness.  There was normal gait and balance noted and UE sensation, reflexes, and motor strength were normal, except for mild decreased right grip strength.  At a PT visit to measure ROM for the MEB approximately 8 months prior to separation, the CI reported neck pain.  ROM of the cervical spine was flexion of 34 degrees (normal 45 degrees), and combined ROM of 255 degrees (normal 340 degrees), with tenderness, guarding, and muscle spasm noted, but without abnormal gait or spinal contour.  As noted in the lumbar spine discussion, at the PEB’s request PT ROM was repeated approximately 4 months prior to separation.  ROM was flexion of 40 degrees and combined ROM of 260 degrees, with painful motion noted.  There was no muscle spasm or additional limited ROM after three repetitions.

At the VA C&P examination performed 9 months prior to separation the CI reported neck pain with radiating pain, numbness and tingling to the RUE.  On examination, there was TTP of the C-spine.  There was full neck ROM with painful motion with no additional loss of motion with repetition or muscle spasm.  Sensation and reflexes were normal.  Cervical muscle strength was 4/5, but there was full strength (5/5) of the shoulder wrist, and fingers noted.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the cervical spine condition 10%, coded 5243 (intervertebral disc syndrome) and the VA rated it 10%, coded 5237 (cervical strain).  The Board considered the evidence in record supports that the CI’s disability due to the cervical spine condition was related to cervical spinal stenosis, aggravated by degenerative spine changes.  The PEB coded IAW §4.71a (musculoskeletal conditions) and rated it based upon painful limited ROM motion and the Board agreed that based upon VASRD spine rating rules in effect at the time of separation the 10% rating was achieved for painful cervical ROM.  The Board reviewed to see if there was support for the next higher rating of 20%, but there was no evidence on the C&P, MEB examinations, or two PT evaluations for the MEB of muscle spasm with an abnormal gait or spinal contour.  The Board next considered if an alternative coding approach would provide a path to a higher evaluation.  The Board noted the neck pain and extremity symptoms were thought to be due to cord compression secondary to spinal stenosis by the neurosurgeon and considered coding analogous to 8010 (myelitis) IAW §4.124a (neurological conditions).  However, there is a VASRD code for spinal stenosis, 5238.  Thus, the Board agreed that the neck pain and limited ROM was properly coded IAW the General Formula for Rating the Spine at 10% as noted above, and that to be recommended for additional disability rating the extremity symptoms would first have to be determined to be separately unfitting as discussed below.  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 cervical spine condition.

The Board next considered if there was evidence to support additional rating for extremity impairment related to cord compression or peripheral nerve impairment due to the cervical spine condition.  However, clinically the CI’s extremity symptoms and findings were not consistent with a cervical radiculopathy due to impingement on a single spinal nerve or nerve root.  Bilateral UE and LE EMG/NCS were negative, which while not ruling out a radiculopathy, does not provide support for one either.  The evidence in record supports that at the time of separation the CI’s disability due extremity symptoms other than pain, primarily RUE weakness, was best described as mild to minimal.  The commander’s statement did not implicate any impaired duty performance except limitations that would accompany neck and back pain conditions, noting only that the CI could not stand longer than 30 minutes or lift more than 10 pounds.  Additionally, the permanent profile noted only cervicalgia with radiating pain due cervical vitro diagnostic medical device, and pain, whether or not it radiates is subsumed in the §4.71a rating.  Thus, the Board concluded that no additional disability ratings could be recommended.

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 matters of the lumbar spine and cervical spine conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  The Board unanimously agreed that no additional disability rating can be recommended for radiculopathy or myelitis related to the cervical spine condition.  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 20140115, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		

SAMR-RB									

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXX, AR20150007693 (PD201400909)

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						
						         
CF: 
(  ) DoD PDBR
(  ) DVA