RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01266
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090427

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Aircraft Hydraulics System Apprentice, medically separated for “chronic low back pain status post fusion of L5-S1,” with a disability rating of 10%.

CI CONTENTION:  The CI contends his condition continues to worsen and negatively impact his daily activities.  The CI’s 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 based upon a 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 - 20090114	VARD - 20100204	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain S/P Fusion L5-S1	5241	10%	Lumbar Spine Fusion 	5241	20%	20091209	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Low Back Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the low back condition began approximately 2 years prior to referral for MEB.  While moving aircraft jacking equipment, an aircraft jack fell over and struck the CI in the back.  Lumbar spine diagnostic imaging (MRI) showed a left L5-S1 disc herniation that impinged upon the left S1 nerve root.  Neurosurgery completed a series of epidural steroid injections (ESIs) for the CI’s severe lumbosacral spondylosis (spine degenerative disease).  He continued to have severe pain in his back and pain extending down the right buttock, posterior thigh, and calf consistent with an S1 distribution radiculopathy (nerve root irritation or injury).  The neurosurgeon opined that if the CI did not improve with continued physical therapy (PT) and light duty, he would likely require an L5-S1 decompression with stabilization at that level.  The CI failed non-operative management and underwent a discectomy and fusion at L5-S1.  At the neurosurgery 3-month follow-up for the L5-S1 decompression and fusion, the CI reported he was doing quite well.  From the standpoint of his surgery, he had very little back pain or leg symptoms.  The physical examination revealed good strength and sensation, bilaterally.  Diagnostic imaging (X-rays) showed stable appearance of the bone grafts and instrumentation.  Lumbar spine diagnostic imaging (CT) showed postsurgical posterior decompression and interbody fusion changes at L5-S1 with good alignment.  There was a left posterior bony outgrowth producing significant left foraminal (nerve root opening) narrowing and contact of the exiting left L5 nerve root.  At a 15 month post-operative neurosurgery follow-up, the CI reported he was still having some back pain.  This was characterized as mechanical back pain that was made worse with walking, bending, or twisting.  The examiner reviewed the CT and documented there was evidence of solid fusion at L5-S1 and the right-sided facet joint.  He indicated the left L5 screw appeared to be adjacent to the mobile portion of the L4 inferior facet.  The neurosurgeon opined that the left L5 screw may be causing some abrasion and may be contributing to the back pain.  He offered to remove the instrumentation on the left and opined that this may provide some relief.  A second opinion evaluation was performed by neurosurgery.  The neurosurgeon reviewed the lumbar spine CT and documented good positioning of the L5-S1 interbody cage, good interbody fusion, and good facet fusion with no misalignment of the bilateral pedicle screws.  The neurosurgeon opined that the treating surgeon had “obviously performed an excellent surgery” and had given the CI “a very good outcome.”  He counseled the CI that it was very difficult to treat low back pain with fusion surgery, and that his degree of improvement was very good.  “I could not tell him for sure if removal of his hardware would take away his pain complaints.”  The assessment listed failed back syndrome (persistent back and/or leg pain following spinal surgery).  

The NARSUM, 7 months before separation, on 15 September 2008, recounted the history and interventions.  The CI reported continued back pain which was exacerbated by prolonged sitting, standing, and walking and somewhat relieved by PT.  He denied lower extremity weakness, numbness, tingling, or loss of bowel or bladder control.  The active medication was the nonsteroidal anti-inflammatory drug (NSAID) Mobic.  The physical examination documented a normal gait.  The back examination revealed tenderness of the L5-S1 region, negative straight leg raise (SLR) tests (assess for herniated disc causing sciatic nerve root [L5-S1] radiculopathy), and limited range of motion (ROM).  Strength and sensation were normal.  The examiner cited the findings from the MRI and neurosurgery and PT consultations.  The diagnosis listed persistent pain and functional limitations.  Thoracolumbar ROM was measured by PT with a goniometer for the MEB.  Repetitive active ROM was flexion of 118/120/120 (90 normal).  

The 9 December 2009 Compensation and Pension (C&P) examination, 7 months after separation, recounted the history and interventions.  The CI complained of intermittent LBP with remissions.  He reported occasional radiation of pain and numbness in the distribution of the right L5-S1 dermatome (area of skin sensation from a single spinal cord nerve root).  Symptoms were associated with stiffness and limited motion but he denied weakness, paralysis, or paresthesias (abnormal sensation, tingling, burning, prickling).  During the past 12 months, the CI reported 5-6 incapacitating episodes, which lasted 2-3 days.  Symptom response to NSAIDs and ice packs was fair.  The physical examination documented a normal gait without an assistive aid.  The back examination revealed 5 non-tender healed surgical incisions.  There was lower back ankylosis (fusion with retained hardware) with no spinal muscle tenderness, guarding, or spasm.  The SLR test was positive on the right (L5-S1 dermatome).  Lumbosacral spine active ROM was flexion of 65 (90), extension of 15 (30), bilateral lateral flexion of 20 (30), and bilateral rotation of 25 (30) degrees.  There was pain with flexion (at 50-65 degrees) and extension (at 10-15 degrees) but none with lateral flexion or rotation.  The diagnosis listed mechanical fusion at L5-S1 with spacer.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5241 code (spinal fusion), citing chronic low back pain, status-post L5-S1 fusion, neurological examination, no sensory abnormalities, normal motor exam, steady gait, and good balance.  The VA assigned a 20% rating under the 5241 code based on the VA C&P examination 7 months after separation, citing lumbar fusion, intermittent lumbosacral spine symptoms with remissions, radiation to both lower extremities, numbness in the right lower extremity, treatment with medication and ice packs, normal gait, no assistive aid, lower back spinal ankylosis, lumbar spine ROM, additional limitation of extension and flexion with repetition due to pain, no additional limitation due to fatigue, weakness, or lack of endurance, no neurological impairment,  and full strength.  The ROM values in the PT for MEB examination did not attain the minimum 10% rating based upon the general rating formula for diseases and injuries of the spine.  The higher 10% rating would require flexion of greater than 60 degrees but not greater than 85 degrees; or a combined ROM of greater than 120 degrees but not greater than 235 degrees of the thoracolumbar spine.  The ROM values in the C&P examination were consistent with the 10% rating.  While the CI reported incapacitating episodes, there was no documentation of incapacitating episodes.  Although the CI experienced occasional radiation of pain and numbness to the right lower extremity, there was no objective evidence of a radiculopathy or functional impairment with a direct impact on fitness.  The Board agreed there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.40, §4.45, and §4.59).  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 low back condition.

BOARD FINDINGS:  In the matter of the low back 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.  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 20140311, 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 XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-01266.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings