RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	 CASE:  PD-2014-01237	
BRANCH OF SERVICE:  Army	 BOARD DATE:  20150721
SEPARATION DATE:  20080410		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Bridge Crewmember) medically separated for chronic neck pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The chronic neck pain condition, characterized as “cervical spine fracture with fusion” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB dated did not include updates from the 2008 NDAA which changed disability rating guidance.  An admin correction was issued with an IPEB dated 14 April 2008 which adjudicated “cervical fusion and chronic neck pain” as unfitting, rated 20%.  The admin correction did not affect the rating.  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 20080415	VA - (2 days Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Fusion And Chronic Neck Pain	5241	20%	Fracture, Cervical, Status Post Fusion C3-C7	5235	10%	20080408	
Other x 0  (Not in Scope)	Surgical Scars, Cervical Spine	7800-7804	10%	20080408	
	Other x 2 	20080408	
Combined:  20%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20080624 (most proximate to date of separation [DOS]).   

ANALYSIS SUMMARY:  

Cervical Fusion And Chronic Neck Pain:  The service treatment record (STR) noted the CI was in process of constructing a bridge when it collapsed.  As a result she fell 13 feet to the ground on 9 March 2007, landed on her back, and had 2-3 minutes of loss of consciousness.  She indicated she broke her neck, several ribs, and “took three chunks out of my right elbow.”  Imaging studies revealed a fracture of the C5 vertebra and the right 8th, 9th, and 10th ribs on the right.  She was medically evacuated and underwent a posterior spinal fusion of C3 to C7 on 12 March 2007 for the unstable C5 fracture and ligamentous disruption at C4-6.  Traumatic brain injury (TBI) evaluation was negative.  Postoperatively, she denied any numbness, tingling, or shooting pain, but did note right sided neck and shoulder pain from her C-collar; and the pain was controlled with Percocet, a narcotic, and baclofen, a muscle relaxer medication.  Physical therapy evaluation on 7 May 2005 revealed restriction of her cervical spine in all directions with flexion grossly at 20 degrees and a combined range-of motion (ROM) of 135 degrees.  By 10 July 2007, the CI was off all medications for 6 to 7 weeks and demonstrated a “good range of motion without significant tenderness.  Neurologic evaluation of the upper and lower extremities was unremarkable.  Physical therapy and TENS (transepidermal nerve stimulation) unit treatments continued. 

A permanent U3 profile was issued on 15 October 2007 for the cervical spine fusion with limitation of most functional military activities except carrying and firing an individual weapon and wearing a protective mask and chemical defense equipment.  The CI could not perform physical fitness training or testing and could not wear protective equipment, march or occupy tactical vehicles.  She was also limited from lifting more than 20 pounds and from flexion or extension neck activities; and, as a result, she felt she could not assume a prone position to fire weapon.  The CI noted on the Report of Medical History (DD Form 2807-1) dated 20 November 2007 that she had a C3-C7 spinal fusion with two rods and ten screws, lost consciousness for “2 min apprx,” and had “trouble sleeping because of constant neck pain.”  The commander’s statement dated 30 November 2007 indicated that “despite her still painful condition [the CI] is a valuable member of the team and can be counted on when others fail.  She still contributes to the mission, but does so at a much reduced capacity due to her limitations.”  She had pain that interfered with her duty assignments, but was doing light clerical work.  

The MEB narrative summary (NARSUM) dated 12 December 2007, noted that the CI’s post-operative course in spite of rehabilitation she complained of persistent neck pain which ranged from 0-7/10 relieved by heat and medication and aggravated by sitting and standing for long periods of time and sleeping.  Her general examination was within normal limits and she was able to ambulate.  The examiner noted on the DD Form 2808, Report of Medical Examination, dated 12 December 2007, that the neck examination showed a well healed scar that measured 13 cm from the base of the occiput to the base of the cervical spine.  The scar was mildly tender to palpation.  The cervical spine ROM was decreased, especially with side bending to the right and rotation to the right, with mild pain associated at the extremes and there was no spasm or guarding noted.  Grip strength was excellent in the upper extremities.  Deep tendon reflexes were normal and no sensory changes were noted.  The remainder of the back examination was within normal limits. 

At the VA Compensation and Pension (C&P) examination dated 4 April 2008, performed 6 days before separation, the CI reported injuries to the cervical spine with constant pain with a limit of 20 minutes of standing or sitting without have to change position.  Additionally she had a residual scar, 13cm by 1cm with mild tenderness, which was flesh colored with minimal redness and raised with no adherence to underlying tissue.  Forward flexion of the cervical spine was 35 degrees and the combined ROM was 195 degrees.  Generalized cervical tenderness was noted with guarding, but no spasm or ankylosis was present.  Neurologic examination was unremarkable, although the CI reported tingling and paresthesia of the 4th and 5th digits of the right hand and numbness directly over the scar of the neck. 

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.

Cervical ROM
(Degrees)	PT ~ 10 Mo. Pre-Sep
	MEB ~ 4 Mo. Pre-Sep
	VA C&P ~6 days Pre-Sep
	
Flex (45 Normal)	20	25	35	
Extension (45)	15	45	20	
R Lat Flexion (45)	10	20	25	
L Lat Flexion (45)	10	25	20	
R Rotation (80)	35	65	40	
L Rotation (80)	35	40	55	
Combined (340)	135	220	195	
Comment	Gross measurements; tenderness to palpation on the incision line, paracervical muscles not tender on palpation	Measurements with an inclinometer; motion limited mechanically postsurgical changes of the fusion rather than pain; no muscle spasm or guarding; mild tenderness over the scar	Flares of pain of the cervical spine with overexertion; generalized cervical tenderness with guarding noted, but no spasm; 13 cm by 1 cm raised scar; DeLuca negative.	
§4.71a Rating	20%	PEB 20%	VA 10% cervical spine; 10% scar	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating using code 5241 (spinal fusion), while the VA assigned a 10% rating using code 5235 (vertebral fracture) for the CI’s cervical fracture, status post fusion C3-C7 and a 10% rating for surgical scars of the cervical spine using analogous code 7800-7804 (unstable or painful scar).  The Board considered whether an additional rating could be recommended under a peripheral nerve code.  Firm Board precedence requires a functional impairment linked to fitness 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.  The Board then sought a route to a higher rating but in the absence of unfavorable or favorable ankylosis of the entire cervical spine the Board was unable to do.  The Board also considered whether the scar was separately unfitting; however, although it was tender to palpation and the CI noted numbness of the scar, there were no functional limitations related directly to the scar and it was neither profiled or implicated in the commander’s statement nor was not judged to fail retention standards.  Therefore, the Board determined the scar could not be recommended for an additional disability rating.  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 fusion and neck 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 cervical fusion and neck pain 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. 

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 20140304, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAMR-RB									

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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXX, AR20150013674 (PD201401237)

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		XXXXXXXXXXXXXXX
			Deputy Assistant Secretary of the Army
			    (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA