RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01457
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080527

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Utilities Equipment Repairer, medically separated for “cervical disc disease” and “lumbar degenerative disc disease,” rated 10% and 10%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:   The CI contends his cervical and lumbar spine conditions continue 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.  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.  

In addition, the Secretary of Defense Mental Health Review Terms of Reference directed a comprehensive review of Service members with certain mental health (MH) conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The MH condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.

RATING COMPARISON:  

SERVICE PEB - Dated 20080331	VARD - 20081230 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Disc Disease 	5243	10%	Cervical Spondylosis and Degenerative Disc Disease with
Radiculopathy	5243	20%	20080916	
Lumbar Degenerative Disc Disease	5299-5242	10%	Lumbar Spine Degenerative Disc Disease	5242	20%	20080916	
PTSD	Not Unfitting	Posttraumatic Stress Disorder With Depressive Disorder, NOS	9411	30%	20080916	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Cervical Disc Disease Condition.  The CI’s history of chronic neck pain began during deployment in 2005.  After re-deployment, his condition improved and he was cleared to deploy again in 2006.  His neck pain worsened during the deployment; however, he was able to complete his deployment, and re-deployed in 2007, although he continued to have neck pain.  The CI reported radicular symptoms to the upper extremities and underwent magnetic resonance imaging (MRI).  In December 2007, MRI of the cervical spine demonstrated central disc protrusion at C5-6 and C6-7, with narrowing of the neural foramen.  MRI was followed by electromyogram (EMG) and nerve conduction studies (NCS) of both upper and lower extremities.  The results of the EMG and NCS were normal; there was no evidence to support acute cervical or lumbar radiculopathy.  At the narrative summary NARSUM on 24 March 2008, approximately 2 months before separation, the CI noted that his neck pain was usually tolerable with medications unless exacerbated by activity.  His pain at times interfered with sleep.  Physical examination of the neck noted mild tenderness to palpation.  Range of motion (ROM) documented forward flexion and extension with 3 trials averaging 41 degrees (NL=45 for each), and a total average of 216 degrees (340).

At the Compensation and Pension (C&P) examination, 4 months after separation, the CI reported he had radiating pain down the arms, and numbness and tingling in the fingertips.  The examiner stated, “He has had no incapacitating episodes in the past 12 months where he was put to bed by a physician.”  Physical examination revealed good muscle strength and reflexes, and normal sensory function.  ROM recorded 25 degrees of flexion and 20 degrees of extension. Grip strength was noted to be good and firm.  There was no additional loss of ROMs on repetition.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition at 10%, coded 5243 (intervertebral disc syndrome) based on ROM total less than 335 greater than 170 degrees.  The VA under the same code granted a 20% based on limitation of motion.  The 5243 code rating takes into account the presence or absence of incapacitating episodes, and functional loss of motion.  Thus, a 20% rating requires forward flexion of the cervical spine of 15 to 30 degrees, or combined ROM of not greater than 170 degrees or spasm not resulting in abnormal gait or abnormal spinal contour, or vertebral body fracture with loss of 50% or more of the height, or evidence of incapacitating episodes with a total duration of at least 2 weeks during the past 12 months.  There was no evidence of ratable peripheral nerve impairment in this case, since no motor weakness was present and sensory symptoms had no functional implication.  There was no evidence of incapacitating episodes for a higher rating under 5243.  Given the record of evidence the Board could not find other applicable VARSD codes for consideration.  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 disc disease condition.  

Lumbar Degenerative Disc Disease Condition.  The NARSUM noted that the CI’s non-traumatic back pain begun during his 2005 deployment and improved on re-deployment.  The CI was able to deploy again in 2006; however, his back pain worsened during the 2006 deployment.  He reported low back pain with radicular symptoms to the lower extremities.  In December 2007, he underwent MRI of the entire spine.  Lumbar spine findings included small disc herniation at L5-S1 without significant nerve root involvement, and normal alignment of the lumbar vertebra.  As noted above, the EMG and NCS of the lower extremities were normal, ruling out the likelihood of an acute lumbar radiculopathy.  The CI was treated conservatively but did not improve enough to perform the duties of his specialty.  At the NARSUM, the CI noted that his pain was generally tolerable with medication but activities worsened his pain.  Physical examination of the lumbar spine noted mild tenderness to palpation.  Lower extremity strength was 5/5, and reflexes were intact.  ROM documented forward flexion average greater than 90 degrees (90, 95, 100), and extension of 20 degrees.  ROM was not limited due to fatigue, weakness, lack of endurance, or incoordination.  
The VA Compensation and Pension (C&P) was accomplished 4 months after separation.  Physical examination recorded forward flexion ROM at 90 degrees.  The CI reported pain at the 90 degree point, most of the pain was in his neck; however, the examiner noted that there was no objective evidence of pain with movement.  The examiner also noted that the CI was able to “repetitive movement of the lumbar area with forward bending to around 45 degrees repetitively but this caused discomfort and he stopped.”  The examiner recorded normal sensation in the lower extremities, and normal muscle strength.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition 10%, coded analogously 5242 (degenerative arthritis).  The VA rated the condition at 20%, coded 5243 for “forward flexion of the 45 degrees”.  A higher rating of 20% requires spasms producing abnormal gait, or abnormal curvature of the spine, or forward flexion not greater than 60 degrees.  The Board noted forward flexion recorded in the C&P examination was consistent with the NARSUM.  The examiner noted that on repetitive bending movement “of the lumbar area,” the CI could bend only to 45 degrees before feeling discomfort.  It was not clear, if the examiner was invoking DeLuca criteria or had attempted to average forward flexion ROM.  It is clear that the C&P documented 90 degrees of lumbar spine forward flexion.  The Board concluded there was not a preponderance of evidence to support the higher rating.  The Board also considered code 5243 (intervertebral disc syndrome); however, this code did not support a higher rating since there was no evidence of incapacitating episodes documented in the record.  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 lumbar degenerative disc disease condition.  

Contended PEB Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that the posttraumatic stress disorder (PTSD) condition was not unfitting.  The Board first reviewed the records for evidence of inappropriate changes in diagnosis of the mental health condition during processing through the military disability evaluation system (DES).  The available evidence of record showed the diagnosis of PTSD was the only diagnosis rendered during processing through the DES.  The Board determined that no mental health diagnosis was changed in the DES process.  This applicant therefore did not appear to meet the inclusion criteria in the Terms of Reference (TOR) of the Mental Health Diagnosis Review Project.  The Board next proceeded in the review of the evidence.  A memorandum to the MEB was prepared by the treating psychologist who noted the CI had been evaluated and treated for PTSD.  The psychologist opined that his psychiatric condition met retention standards and did not warrant processing through the MEB, nor required an addendum or NARSUM.  No mental health condition, including The PTSD, was profiled or implicated in the commander’s statement and none was judged to fail retention standards.  All available records were reviewed.   There was no performance based evidence from the record that any mental health 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 the PTSD condition and so no additional disability rating is recommended.  

BOARD FINDINGS.  In the matter of the cervical disc disease condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the lumbar degenerative disc disease condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended PTSD 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, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXXXX AR20160008655 (PD2014-01457)

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
( ) DVA