RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX			CASE:  PD-2014-01229
BRANCH OF SERVICE:  Army	 SEPARATION DATE:  20091227

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Army E-6, Chemical Operations Specialist, medically separated for “thoracolumbar degenerative disc disease,” with a disability rating of 10%.

CI CONTENTION:  His back continues to worsen and was not properly evaluated.  His 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 Physical Evaluation Board (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 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 - 20090930	VARD - 20100104	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Thoracolumbar Degenerative Disc Disease	5242	10%	Thoracic Spine Degenerative Changes and Lumbar Strain	5242	10%	20090519	
Degenerative Arthritis
Changes of Cervical Spine	Not Unfitting	Cervical Spine Degenerative Arthritis	5242	10%		
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:

Thoracolumbar Spine.  The service treatment record (STR) and narrative summary (NARSUM) documented an initial visit to the emergency room for a back injury in March 2007 (3 years pre-separation).  Radiographic evaluation in March and April 2007 documented normal lumbosacral spine (normal vertebral height, disc spacing; no evidence of traumatic, inflammatory, cancerous or significant arthritic change); and minimal degenerative changes at T9-T10 with no advanced degenerative changes, normal disc spaces and alignment.  Radiographic evaluation in August 2008 (16 months pre-separation) documented similar thoracic spine findings (normal vertebral height and contour, normal disc spacing, with no traumatic, inflammatory, cancerous or significant arthritic change) with “mild” degenerative changes at T8 and T9 and normal T10.  At an orthopedic consultation in October 2008 (14 months pre-separation), the CI reported mid to left sided thoracic back pain, aggravated by activity and random movements, and denied weakness, numbness, tingling or bowel and bladder complaints.  The examiner documented no tenderness; normal strength, sensation, reflexes; and normal range-of-motion throughout.  Radiographic imaging of the thoracic and lumbar spine in May 2009 (7 months pre-separation) documented similar findings to prior evaluations.  There was no STR documentation of more significant range-of-motion measurements, and no documentation of physician prescribed bed rest for incapacitating episodes.  On the MEB DD Form 2807-1, Report of Medical History, dated 11 February 2009 (10 months pre-separation), the CI reported “upper back pain, T spine, shoulder blade, muscle spasms, neck, and lower back sprain 2007.”

At the VA Compensation and Pension (C&P) examination dated 19 May 2009 (7 months pre-separation), the CI reported stiffness, and localized back pain that occurred 20 times per day and lasted less than an hour.  He denied functional impairment and any episodes of incapacitation.  The examiner documented a normal gait, normal spinal curvature, no spasm or tenderness, and no evidence of radiation or nerve traction.  Flexion was to 90 degrees, and all other ranges-of-motion (ROM) were normal.  Painful motion occurred with flexion and extension.  There was no change in ROM with repetitive testing.  The examiner documented no signs of intervertebral disc syndrome.

The MEB NARSUM examination was dated on 30 June 2009 (6 months pre-separation).  The CI reported daily mid thoracic back pain.  The examiner referenced the VA physical examination performed on 5 June 2009 and documented normal gait, no tenderness, no spasm, and no radiating pain on motion.  Flexion was to 90 degrees (normal), and all other ROM were normal (extension, bilateral flexion, bilateral rotation all to 30 degrees each).  Painful motion occurred with flexion and extension.  There was no change in ROM with repetitive testing.

The Board directed attention to the rating recommendation based on the above evidence.  The PEB adjudicated the “thoracolumbar degenerative disc disease” as unfitting, rating 10% coded 5242 (degenerative arthritis of the spine).  The VA rated and coded identically.  The Board considered the evidence for a higher than 10% rating.  There was no evidence of forward flexion greater than 30 degrees but not greater than 60 degrees in support of a higher rating.  There was no documentation of spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour for a higher rating.  There was no documentation of physician prescribed bed rest for incapacitating episodes for a higher rating under code 5243.  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 10% for the thoracolumbar spine condition was appropriately recommended in this case.

Contended PEB Condition.

Cervical Spine.  The cervical spine condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  It was reviewed and considered by the Board.  There was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for this condition and so no additional disability rating is recommended.
BOARD FINDINGS:  In the matter of the thoracolumbar spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended cervical spine condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 20140219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency (AHRC-00), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXX AR20160005847  (PD201401229)

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:

Enclosure 

CF:
( ) DoD PDBR 
( ) OVA