RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01472
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090626

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E6, Avionics Test Stations and Components Craftsman, medically separated for “cervicalgia due to herniated C5-7 associated with spinal stenosis,” with a disability rating of 20%.  

CI CONTENTION:  The CI contends that his condition continues to worsen and negatively impact his daily activities and that the MEB did not rate his carpel tunnel syndrome, which the VA rated at 20%.  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 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 - 20090403	VARD - 20100310	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervicalgia due to Herniated C5-7 associated with Spinal Stenosis 	5238	20%	Degenerative Joint Disease C4-C7 with Posterior Osteophytes with an Abutment of the Ventral Cord at C5-6	5242	10%	20100203	
Bilateral Carpal Tunnel Syndrome	Cat II	Carpal Tunnel Syndrome, Left Upper Extremity	8599-8515	10%	20100203	
		Carpal Tunnel Syndrome, Right Upper Extremity	8599-8515	10%	20100203	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Neck.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck condition began in 1998 after a motor vehicle accident and likely exacerbated in January 2008 after falling.  At a 23 January 2008 physical therapy (PT) appointment, 17 months before separation, the CI reported 4/10 neck pain without radicular (nerve root irritation or injury) pain or motor loss.  The physical exam revealed tenderness at the C6-7 spinous process with no deformity or swelling.  Cervical range of motion (ROM) was flexion of 75% ~ 35 (normal 45), extension of 100% ~ 45 (normal), left rotation of 75% ~ 60 (normal 80), right rotation of 50% ~40 (normal 80), and bilateral lateral flexion of 75% ~ 35 (normal 45) degrees.  The assessment listed cervicalgia (neck pain).  In February 2008, magnetic resonance imaging (MRI) showed suspected congenital (inborn physical abnormality or disease) spinal stenosis (narrowing), additional stenosis at the C4 through C7 discs from degenerative changes, and a small C5/6 disc herniation producing cord impingement.  At an orthopedic visit, the CI reported 5/10 dull neck pain which increased to sharp 10/10 pain with “wrong” movements.  Pain constantly radiated into both shoulders (R>L) with associated numbness and tingling in the palms, ring fingers, and long fingers (R>L).  The neck exam revealed right-sided tenderness with non-tender spinous and transverse processes but no muscle spasm, instability, or weakness.  Strength, sensation, and deep tendon reflexes (DTRs) were normal.  Flexion, extension and rotation were “abnormal” with pain elicited by motion.  The assessment listed cervical spinal stenosis and herniated disc at C5-C6.  

A 4 April 2008 MRI showed C5-C6 and C6-C7 disc protrusions causing moderate spinal canal stenosis with the some flattening of the cord surface and minimal DDD at C4-C5 without stenosis.  At an orthopedic appointment the same week, the CI reported neck pain with radicular symptoms.  Physical exam recorded a positive Spurling’s test (assesses cervical nerve root compression by a herniated disc) bilaterally.  Wrist Tinel’s (percussing carpal tunnel elicits tingling over median nerve distribution) and carpal compression (compressing carpal tunnel elicits tingling over median nerve distribution) tests were negative.  Bilateral wrist extensor, wrist flexor, and hand intrinsic muscle strength measurements were normal and the triceps were mildly weak.  The assessment listed cervical spondylosis (spine degenerative disease) with C5, C6, and C7 neurologic compression; the surgeon discussed the possibility of surgery with the CI.  

At the neurology appointment on 16 April 2008, 15 months before separation, the CI complained of progressive numbness and subjective weakness in both palms over the last year.  He reported shooting pain down his left arm into his hand when he turned his head.  Upon physical exam, a Spurling’s test was positive bilaterally with left lower cervical radicular pains; Lhermitte's sign (assesses pathological compression of the cervical spinal cord) was negative.  Upper extremity strength was normal and DTRs were decreased.  There was decreased sensation (light touch, pinprick and temperature) in the left arm and in the median nerve distribution (L>R) of the palms.  The bilateral wrist and left elbow Tinel’s tests were positive.  The examiner suspected the etiology of the left arm radicular pain was nerve root irritation due to cervical stenosis and disc herniation at C6-7 and less likely C5-6.  He suspected the bilateral hand symptoms were due to carpal tunnel syndrome (CTS) and the neck and shoulder pains were due to cervical spondylosis/stenosis.  The assessment listed cervical spondylosis.  During a physical medicine and rehabilitation (PM&R) encounter on 17 April 2008, the CI reported superficial bilateral neck pain that increased with flexion and extension.  He also complained of associated upper back pain radiating to the upper extremities with tingling and numbness but denied motor disturbances.  The neck exam revealed a normal appearance and cervical spine motion.  Pain was elicited by motion with posterior tenderness but no instability or weakness were noted.  An electrodiagnostic study showed findings most consistent with mild bilateral CTS (R>L).  The assessment listed cervicalgia and mild bilateral CTS.  Despite treatment, to include an indication for surgery (which was not performed due to other family medical issues), the cervical spine condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred for a MEB.  The MEB forwarded “herniated cervical disc” for PEB adjudication.  

At the MEB NARSUM exam on 15 Oct 2008, 9 months before separation, the CI complained of weakness in the left shoulder and arm as well as left arm radicular pain when he turned his head to the left.  On exam there was a positive Spurling’s test bilaterally for cervical nerve root compression.  Lhermitte signs for spinal compression were positive.  Distal pulses were 2+ in the upper extremity (UE).  Motor strength was 5/5 in the wrist extensors and flexors and hand intrinsics and 4+/5 in the triceps.  The NARSUM referenced the electrodiagnostic study which showed mild bilateral CTS but was otherwise unremarkable.  During a PT appointment on 14 January 2009, performed 5 months before separation, the CI reported 4/10 neck pain which was worse a month prior at 9/10 with intermittent numbness in the bilateral UE and intermittent radiating pain in the bilateral shoulders.  On exam, there was no tenderness to palpitation or radicular complaints elicited with testing.  The DTRs were 1+ in the right UE and 2+ in the left UE and motor strength was normal (5/5) in the bilateral UEs.  Cervical ROM was forward flexion of 25 with a combined ROM of 180 (normal 340) degrees.  

A VA Compensation and Pension (C&P) exam performed ton 3 February 2010 7, months after separation, the CI reported that he missed 2 days of work and experienced 3 episodes of incapacitation in the past year due to neck pain.  The examiner noted the CI did not wear a cervical collar or neck brace.  The physical exam showed upright and erect posture with no notable muscle spasms.  The DTRs were symmetrical in the UEs.  Sensory functions were symmetrical except for the thumb, index fingers and long fingers of both hands.  Motor strength was diminished at the right biceps, right triceps and with dorsiflexion and extension of the right wrist; there was difficulty with strength against resisted adduction and flexion which “did seem to exacerbate his neck pain.”  Motor and sensory functions were grossly intact except for reported paraesthesias in the thumbs, index and long fingers in both hands.  No ROM values were documented in the exam. 

The ROM exams 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~17 Mos.
Pre-Sep	PM&R MEB ~14 Mos. Pre-Sep 	PT for MEB~5 Mos. Pre-Sep	VA C&P ~7 Mos.
Post-Sep	
Flexion (45 Normal)	(35) 75%	NORMAL	(25) 26	NO ROM MEASURED	
Combined (340)	>250	NORMAL	180	NO ROM MEASURED	
Comments	Flexion
Tenderness	Painful motion
Tenderness	Flexion	Flexion and CROM	
§4.71a Rating	10%	0%	20%	-	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% under the 5238 code (spinal stenosis), citing limitation of forward flexion.  The VA assigned a 10% rating under the 5242 code (degenerative arthritis of the spine) citing limitation of forward flexion and combined ROM (an October 2010 Decision Review Officer rating corrected and changed this to a 20% rating effective the day after the CI’s date of separation).  The Board agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 15 degrees but not greater than 30 degrees) reported on the MEB PT exam.  

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The PT, MEB NARSUM, and VA C&P exams proximate to separation revealed no objective findings of radiculopathy that would impact duty performance.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore the critical decision is whether or not there was a significant neurologic impairment which would impact military occupation specific activities.  There was no evidence in this case that a neurologic abnormality existed to any degree that could be described as functionally impairing.  The Board therefore concluded that an additional disability rating was not justified on this basis.  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 cervicalgia due to herniated C5-7 associated with spinal stenosis condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that bilateral CTS condition was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The bilateral CTS condition was not specifically profiled or implicated in the commander’s statement and was not judged to fail retention standards.  The bilateral CTS condition 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 at separation.  After due deliberation, and 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 bilateral CTS contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the cervicalgia due to herniated C5-7 associated with spinal stenosis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended bilateral CTS condition, the Board unanimously recommends no change from the PEB determinations 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 20140425, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
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-2014-01472.

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