RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00925
BRANCH OF SERVICE:  Army 	BOARD DATE:  20150717
SEPARATION DATE:  20090303

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Food Service) medically separated for a neck condition. The neck condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent U3 profile and underwent a Medical Evaluation Board (MEB).  Post-operative cervical stenosis, degenerative joint disease (DJD), cervical unco-vertebral joint hypertrophy, and chronic post-operative cervicalgia were forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501.  The MEB also forwarded gastroesophageal reflux disease (GERD) and hypertension (HTN) as meeting retention standards.  The Informal PEB (IPEB) adjudicated DJD of the cervical spine, with chronic cervicalgia as unfitting, rated 20%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The GERD and HTN conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  His cervical condition continues to worsen and negatively impact his daily activities.  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 condition 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 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 20081119	VA* - (~1 Mo. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
DJD of the Cervical Spine	5242	20%	C3-C4 Disc Disease, with Residual Scar	5242	20%	20090407	
Other MEB/PEB Conditions x 2 (Not In Scope)	Other x 1	
RATING:  20%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20090609 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Neck pain.  In October 1996, this CI suffered a neck injury.  He was treated with conservative measures.  On 10 March 2004, magnetic resonance imaging (MRI) showed moderate canal stenosis (narrowing) at C3-C4, and a large right disc protrusion at C6-C7, resulting in moderate stenosis of the C7 neural foramen.  Repeat MRI in January 2008 showed that the C6-C7 disc protrusion was still there, but was slightly decreased in size.  In February 2008, the CI underwent a discectomy and fusion at C3-C4.  After surgery, his symptoms persisted, and an MEB was initiated.  The MEB physical examination (PE) was in October 2008.  The CI was in no acute distress.  PE of the neck revealed moderate tenderness to palpation (TTP) and some muscle spasm was noted.  Muscle tone and bulk was normal.  Motor strength and deep tendon reflexes (DTRs) in both arms was normal.  He was able to heel-toe and tandem walk without increasing his neck pain.  Cervical range-of-motion (ROM) was measured with a goniometer and is summarized in the chart below.

The CI was separated on 3 March 2009.  One month later, on 7 April 2009, he had a VA Compensation and Pension (C&P) exam.  The CI reported that his neck pain was constant.  Sometimes the pain traveled down the left arm.  On PE, his posture and gait were normal.  Neurological exam was normal.  Spinal ROM was measured, and is summarized in the chart below.  The C&P examiner wrote “Thoracic spine.”  After careful review of all the information in the record, the Board concluded that this was an administrative error.  It was more likely than not, that the C&P examiner had intended to write “Cervical spine” when describing the spinal ROM.  The range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its recommendation are summarized in the chart below.

Cervical ROM
(Degrees)	MEB ~ 5 Mos. Pre-Sep
	VA C&P ~ 1 Mo. Post-Sep
	
Flex (45 Normal)	25	35	
Extension (45)	10	40	
R Lat Flexion (45)	20	15	
L Lat Flexion (45)	10	15	
R Rotation (80)	30	15	
L Rotation (80)	30	25	
Combined (340)	125	145	
§4.71a Rating	20%	20%	
          
The Board directed attention to its rating recommendation based on the above evidence.  The Army PEB and the VA both used VASRD code 5242 (Degenerative arthritis of the spine) and assigned a disability rating of 20%.  At both of the neck exams described above, combined cervical ROM was not greater than 170 degrees.  IAW the VASRD §4.71a General Rating Formula for Diseases and Injuries of the Spine, a 20% rating is warranted when combined ROM of the cervical spine is not greater than 170 degrees.  Therefore, the Board determined that a rating of 20% was appropriate for the unfitting neck condition.  There was no path to a higher rating, because there was not sufficient evidence of a seriously disabling neck condition or spinal abnormality which would justify a higher rating. 
 
The Board also considered the matter of radiculopathy.  After review of all the information in the record, there was insufficient evidence of a clinically significant radiculopathy that interfered with performance of military duties. The CI did have neurological symptoms, but there was insufficient performance-based evidence that his neurological symptoms caused any significant interference with performance of military duties.  Therefore, the Board concluded that there was no unfitting radiculopathy present at separation.  Furthermore, it was noted for the record, that IAW the VASRD §4.71a General Rating Formula for Diseases and Injuries of the Spine, a disability rating based on spinal ROM shall be applied with or without symptoms such as pain (whether or not it radiates).  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 of the unfitting neck 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 unfitting neck condition (degenerative joint disease of the cervical spine, with chronic cervicalgia) 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 2014, 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 XXXXXXXXXXXXXXX, AR20150013676 (PD201400925)

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