RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX						            CASE:  PD-2014-01058
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20090909

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E-6 (Aerospace Maintenance Craftsman) medically separated for a low back pain condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS).  He was issued a temporary P4L4 profile and referred for a Medical Evaluation Board (MEB).  The “recurrent lower back pain” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “low back pain” as Category I:  unfitting, rated 10%, citing application of the Department of Defense guidance for applying the Veterans Administration Schedule for Rating Disabilities (VASRD).  The CI initially made an appeal to the Formal PEB but later withdrew his request and was then transferred to the Reserve Retired List. 

CI CONTENTION:  His 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 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 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:  

IPEB - Dated 20090409	VA* - (~2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5243	10%	Lumbar Disc Disease with Radiculopathy	5241	10%	20091118	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 12 	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20100128 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Low Back Pain Condition.  The service treatment record (STR) indicated the CI had a long history of lower back pain.  The first incident in the STR was in 1998, when the CI was holding a toebar one of the drivers pulled forward.  As a result he was jerked forward and pulled his back, which was treated with Naprelan (naproxen, a nonsteroidal anti-inflammatory drug (NSAID)) and chiropractic adjustments.  A review of his condition in March 2001 indicated that on 8 January 2000 the CI was bent over to the left and was picking up an escape slide to install it when he complained of lower back pain mostly on the left that radiated to the left buttock and thigh. Through 2001, he had treatment that resolved the chronic lumbosacral strain.  X-rays from that time demonstrated a Grade I spondylolisthesis (a vertebra slips forward onto the vertebra below it) of L5 on S1 with disc narrowing and malformation of the L5 vertebrae with congenital malformed facets at L4-5.  An MRI in August 2005 showed degenerative disc disease of the lumbar spine as well as the aforementioned spondylolisthesis.  On 23 October 2007 the CI presented with acute low back pain in the morning after putting on his socks; the day before he had been jogging at the beach.  Treatment consisted of ketorolac, (an NSAID), tramadol (an opioid-like medication), and Parafon Forte (chlorzoxazone, a muscle relaxant) along with a topical analgesic cream consisting of menthol and methyl salicylate (Thera Gesic).  An MRI revealed a straightened curvature without a compression fracture as well as previously noted findings, a partial thickness tear of the L4-L5 herniated disk annulus fibrosis, multilevel anterior vertebral body osteophytosis (arthritic changes) with posterior disc protrusions.  In November 2007 after sneezing, he developed severe low back pain and pain into the bilateral hips, but he had no bowel or bladder dysfunction.  A neurosurgeon noted a left L2-3 disk herniation on a new MRI that correlated with the CI’s left leg anterolateral leg pain and associated numbness.   On 16 November 2007 the CI underwent spine surgery (hemilaminectomy, microdiscectomy, and foraminotomy) for the L2-L3 herniated disk.  In January 2008 the CI experienced progressive low back pain and a review of a postoperative MRI revealed anterolisthesis (forward slippage) of L5 on S1 as well as a bilateral pars defect of the L5 and severe facet arthrodesis (surgery induced ankylosis).  In February 2008 the CI had sharp pain when bending forward and had continued low back pain radiating to the left lower extremity.  Because of imaging results demonstrating a bilateral pars defect at L5 and lumbar stenosis, an L4-S1, a lumbar laminectomy was recommended and was subsequently performed on 25 March 2008.   Postoperatively, the CI had right sided low back pain with radiation to the right buttock.  An MRI revealed a postoperative fluid collection, which was aspirated under CT-guidance.  At 5 weeks postop the CI had a local infection at the operative site that was treated successfully with Duricef (cefadroxil, an antibiotic).  At the end of May 2008, the CI reported he could not sit, stand, or lie on his left side for a long period of time.  The neurosurgeon felt the pain may be possibly related to muscle spasms and prescribed Skelaxin (metaxalone, a muscle relaxant) and Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever).  A lumbar spine myelogram/CT scan from June 2008 revealed spinal stenosis two levels above the surgery at L2-3.  Orthopedic evaluation in July 2008 indicated the CI’s symptoms were predominantly in the posterior thigh and calf on the left and were consistent with his prior lumbar instability L5-S1 and prior fusion and not consistent with the mild stenosis at L2-L3.  Surgery was not recommended at that time, but a trial of Neurontin (gabapentin, for nerve pain) was recommended.  In September 2008, the CI remained symptomatic with improvement of paresthesias of the feet.  On examination he had no demonstrable sensory loss, motor loss, or atrophy.  X-rays of the lumbar spine showed intact fixation at L4-S1 without evidence of metal failure or loosening, but there was not abundant bone graft or solid arthrodesis.  In March 2009 he was clinically doing poorly with intermittent pain in the left buttock and posterior thigh.  The CI tolerated forward flexion and had increased pain with trunk extension beyond neutral, but had no pain with rotation of the hips.  The CI was to attempt to lose weight and exercise routinely.  The orthopedic surgeon felt the CI reached a point of maximum medical improvement and was unlikely to resume his prior level of function.    

A revised temporary P4L4 profile was issued on 10 May 2008 with limitations of physical fitness testing, lifting greater than 10 pounds, and no prolonged standing or crawling.  Desk duty only was recommended.  The MEB narrative summary (NARSUM) dated 22 December 2008 noted the CI continued to be on limited duty with a 6-hour duty day and 15-pound weight lifting restrictions, which was in contradistinction to his functional job requirements of lifting 80+ pounds and having to walk, stand, and bend for up to 4 hours each day.  Range-of-motion (ROM) measurements in January 2009 with which the CI had increased pain with repetition are in the chart below.  The commander’s statement dated 29 December 2008 indicated the CI had not been able to perform duties since he aggravated his lower back jogging on the beach during a TDY.  The CI missed work from November 2007 until July 2008 when he returned with limited, light duty requirements and a 4-hour work restriction.  It was the commander’s opinion that the CI should return to duty but cross-train into a less demanding career field commensurate with his limitations.

Almost 2 weeks post-separation, the CI had a neurosurgical evaluation in April 2009 at which time he complained of low back pain that radiated in the left anterior lateral thigh along with constant shooting pains in the feet and numbness and tingling in the legs without any bowel or bladder dysfunction.  The neurologic examination was notable for diminished sensation to light touch in the left lateral thigh while the remainder of the exam was within normal limits.  Surgery was not recommended, but the CI was recommended to have a series of lumbar epidural steroid injections. 

At the VA Compensation and Pension (C&P) examination dated 18 November 2009, performed 2 months after separation, the CI reported that since separation he had three spinal injections in a pain clinic that provided temporary relief for 2 weeks and he had one visit to an emergency room in September 2009 where he received an injection and pain medication.  X-rays indicated the rods and screws were intact.  On examination the ROM measurements were flexion 60 degrees, extension 0 degrees, right and left bending 15 degrees each, and right and left rotation 30 degrees each.  All motions were with pain and the CI did not perform repetitive motions because of concern of increased pain.  There was no tenderness with palpation of the lumbosacral area.  Straight leg raises (to determine nerve root irritation) were negative.  The CI’s gait was normal and neurologic evaluation was unremarkable.

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

Thoracolumbar ROM
(Degrees)	PT ~20 Mos. Pre-Sep
	MEB ~8 Mos. Pre-Sep
	VA C&P ~2 Mo. Post-Sep
	
Flexion (90 Normal)	50%	(70)90,75,70	60	
Extension (30)	25%	(15)20,20,17	10	
R Lat Flexion (30)	100%	(20)10,17,20	15	
L Lat Flexion (30)	100%	(20)15,22,20	15	
R Rotation (30)	50%	(30)40,40,43	30	
L Rotation (30)	50%	(30)35,45,45	30	
Combined (240)	-	175	160	
Comment	S/P microdiscectomy	Increased pain with repetition	Pain with motion; repetition refused	
§4.71a Rating	-	PEB 10%	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The Air Force PEB assigned a 10% rating using code 5243 (intervertebral disc syndrome) for low back pain status post microdiscectomy and laminectomy.  The VA assigned a 10% rating using code 5241 for lumbar disc disease with radiculopathy status post microdiscectomy and laminectomy.  The Board sought a route for a higher rating and noted the VA examination was more proximate to separation than the MEB examination.  From a probative value standpoint, its ROM measurements are within 12 months of separation and are useful for rating purposes.  Therefore, with 60 degrees flexion, a 20% rating is reasonable.  Furthermore, it appeared the VA may have used rating criteria for the cervical spine in making its rating determination.  The Board sought a route to a higher rating but was unable to find one in the absence of forward flexion 30 degrees or less, ankylosis of the entire thoracolumbar spine, or incapacitation.  Functional impairment linked to fitness is required to support a recommendation for addition of a peripheral nerve rating to disability in spine conditions.  Although the pain component of the neuropathy is appropriately subsumed in the spine rating IAW VASRD §4.71, which states that “rating is performed with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease,” there was no sensory component with any significant functional implications and no motor weakness was in evidence.  Therefore, a radiculopathy could not be recommended for additional disability rating.  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 pain 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 low back pain condition, the Board unanimously recommends a disability rating of 20%, coded 5241 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	
Low Back Pain 	5241	20%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140227, w/atchs
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 XXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-01058.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of the disability rating without modification of your placement on the Retired Reserve List. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

XXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
1.  Directive
2.  Record of Proceedings

cc:
SAF/MRBR