RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXX						            CASE:  PD-2014-01470
BRANCH OF SERVICE:  AIR FORCE 	SEPARATION DATE:  20090622 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Surgical Service Journeyman) medically separated for a cervical spine condition which could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards.  She was issued a temporary U4 profile and referred for a Medical Evaluation Board (MEB).  The diagnosis “cervicalgia” was forwarded as the sole submission to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The Informal PEB adjudicated “cervicalgia, status post C4-5 discectomy and fusion” as unfitting, rated 10%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI requests a higher rating and elaborates her current disability, specifically referencing “debilitating back and neck pain, right hip pain, hypothyroidism, trigeminal neuralgia, frequent chronic migraines, weakness and numbness in my arms, etc.”  The full 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 20090304	VA* - (5 Wk. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervicalgia ...	5241	10%	Residuals, Cervical Spine Fracture 	5242-5237	10%	20090803	
Other x 0 	Other x 2	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20091013 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Cervical Spine.  The service treatment record (STR) corroborated the history in the narrative summary (NARSUM) of an initial injury to the cervical spine from a motor vehicle accident in April 2007 (26 months prior to separation).  The CI was diagnosed with cervical fractures (stable C3 and C4 vertebral bodies, C4 pedicle, jumped facet right C4 on C5) which were treated with traction (cervical tongs) with an eye to future surgery.  The CI eventually declined further surgical intervention, deciding that the symptoms “were tolerable”; this was judged to be a reasonable decision.  There were multiple STR entries which documented the absence of neurological complaints other than intermittent bilateral upper extremity paresthesias, and normal (or nearly so) neurological findings; the majority recording 5/5 strength, but two neurology entries that noted 4+/5 in some right upper extremity groups (normal sensory and reflex findings in all STR exams).  There were some STR entries which noted non-specifically decreased cervical range-of-motion (ROM), especially with right rotation and side-bending, but others observing grossly normal ROM.  There was one exam note and some imaging reports that mentioned cervical spine contour abnormalities, but these were not sufficiently correlated with spasm and guarding to justify this rating criterion.  There were no STR entries contrary to any of these ratable features, or documentation of incapacitating episodes.  The NARSUM was conducted 13 November 2008 (7 months prior to separation) and documented “continuing [neck pain] ... worsening as the day progresses” (no mention of radicular symptoms) prohibiting contact sports or lifting greater than 10 pounds.  The NARSUM physical examination recorded tenderness without spasm, normal strength and neurologic findings, and “full” ROM (no formal ROM measurements in Service evidence).  

A VA Compensation and Pension (C&P) examination was conducted 3 August 2009 (5 weeks after separation) and documented “continuous pain and stiffness in her neck” which was characterized as “severe,” noting that sensory complaints or weakness were denied, but not elaborating functional limitations.  The VA physical examination recorded tenderness without spasm and detailed normal neurological findings.  The VA measured ROM was 35 degrees flexion (normal 45) and combined ROM of 260 degrees (normal 340).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating under code 5241 (spinal fusion) was consistent with VASRD §4.71a criteria.  The VA’s 10% rating under 5242-5237 (degenerative arthritis of the spine rated as cervical strain) was consistent with the C&P findings and measured ROM.  There was insufficient evidence of abnormal spinal contour to achieve a higher rating, no evidence of additionally ratable peripheral nerve impairment, and no documentation of incapacitating episodes would provide for a higher rating under that formula.  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 of the cervical spine 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 spine 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 20140325, 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 XXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-01470.

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