RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01525
BRANCH OF SERVICE:  Army	BOARD DATE:  20150121
Separation Date:  20091004

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (M1 Armor Crewman) medically separated for thoracolumbar and cervical spine pain.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  Alternate bike, swim and walk fitness tests were authorized.  He was issued a permanent U3/L3 profile and referred for a Medical Evaluation Board (MEB).  The neck and back condition, characterized as “lumbar degenerative disc disease” and “cervical degenerative disc disease,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded five other conditions (occipital neuralgia, cluster headaches, nightmare disorder, panic disorder and enthesopathy) for PEB adjudication.  The Informal PEB adjudicated the thoracolumbar and neck pain conditions as unfitting, rated 10% and 10%, referencing the VA Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfit.  The CI made no appeals and was medically separated.

CI CONTENTION:  “All conditions sleep apnea, PTSD, neck and back degeneration”

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:

Service IPEB – Dated 20090608	VA - (1.5 Mos. Pre -Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Thoracolumbar Spine Pain	5299-5243	10%	Degenerative Disc Disease (DDD) – Lumbar Spine	5242	10%	20090813	
Chronic Neck Pain	5299-5243	10%	DDD – C-Spine	5242	10%	20090813	
Occipital Neuralgia	Meets Retention Stds	No VA Entry	
Cluster Headaches	Meets Retention Stds	Recurrent Cluster Headaches	8199-8100	0%	20090813	
Nightmare Disorder	Meets Retention Stds	Nightmare Disorder	9412	NSC	20090813	
Panic Disorder	Meets Retention Stds	PTSD w/ Anxiety Disorder & NOS Panic Attacks & Depressive Dis	9411	30%	20090813	
Enthesopathy	Meets Retention Stds	No VA Entry	
Other x0	Other x4	
Combined:  20%	Combined:  80%	
Derived from VA Rating Decision (VARD) dated 20091216 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  

Thoracolumbar Spine Pain Condition.  While on deployment in January 2007, the CI developed lower back pain which radiated to the left lower extremity after heavy load work.  He was evaluated and diagnosed with low back strain.  The examiner ordered a non-steroidal anti-inflammatory drug and put the CI on a profile for 4 days with restrictions of no lifting or running.  The lumbar spine X-ray and thoracic spine X-ray were both normal.  The CI had an episode of acute low back pain (LBP) and was evaluated in the emergency room on 11 September 2008.  A lumbar spine magnetic resonance imaging (MRI) demonstrated L4-5 and L5-S1 DDD; L4-5 mild left paracentral disc protrusion and mild left foraminal narrowing and L5-S1 mild right paracentral disc protrusions with a posterior annular tear.  The CI was referred to physical therapy (PT) for LBP rated 4/10 in intensity, which would awaken him frequently and was worse in the mornings.  The physical exam findings were limited flexion with symptoms that radiated to the left lower extremity; however there was normal motor, sensory and reflex testing.  The CI underwent 6 weeks of intense PT without complete back pain resolution.  The orthopedist documented low back complaints that were consistent with DDD.  The Physical Medicine examiner documented that the CI reported a constant ache in his lower back, rated at 4/10 and worsened to 8/10 with all movements along with pain that radiated down his right leg.  There were physical exam findings of pain limited flexion to 60 degrees and all range-of-motion (ROM) limited by pain, although the motor, sensory and reflexes were normal.  The commander’s statement indicated that the CI’s profile prevented him from performing his MOS and rendered him non-deployable.  The MEB Addendum exam approximately 10 months prior to separation documented that the CI had rare occasional episodes of back pain that radiated to his posterior thigh and calf.  There was no physical exam done at this exam.  The MEB narrative summary (NARSUM) exam approximately 9 months prior to separation documented that almost any type of physical activity could significantly aggravate his LBP which was described as a dull ache type sensation and ranged in intensity from 4/10 to 8/10.  The CI reported that there was an improvement in the sciatica pain.  The MEB NARSUM physical exam findings are summarized in the chart below.  The CI was given a permanent L3 profile for LBP (DDD) and another medical condition, with a Code C and specific restrictions noted on the profile.  The pain management provider noted that the CI reported constant lower back soreness and was agreeable to a series of three epidural steroid injections (ESI’s).  The CI received one ESI’s under fluoroscopy on 23 February 2009, 9 April 2009 and 3 June 2009.  The Pain Management provider documented that the CI had a minimal back pain relief from the ESI’s and the examiner was considering further injections or other medical treatment.  The VA Compensation and Pension (C&P) exam approximately 2 months prior to separation documented that the CI reported that damp, cold weather aggravated his back and the pain would radiate to his bilateral hips in the form of sciatic pain. The VA C&P physical exam findings are summarized in the chart below.
There were two ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Thoracolumbar ROM (Degrees)	MEB ~9 Mos. Pre-Sep	VA C&P ~2 Mos. Pre-Sep	
Flexion (90 Normal)	80	80	
Combined (240)	220	220	
Comment	Pos. painful motion; No spasm; Normal strength, sensation & reflexes; Pos. tenderness to palpation	Pos. painful motion; No spasm; No Deluca criteria; Normal strength, sensation & reflexes	
§4.71a Rating	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the thoracolumbar spine pain condition as 5299 analogous to 5243 (Intervertebral disc syndrome) and rated at 10%.  The VA coded the DDD-lumbar spine condition as 5242 (degenerative arthritis of the spine) and rated at 10%.  The General Rating Formula for Diseases and Injuries of the Spine considers the CI’s pain symptoms “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.”  The CI met the 10% rating criteria for “Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees” and “combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees.”  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 thoracolumbar spine pain condition.

Chronic Neck Pain Condition.  The CI injured his neck during combative training.  During his deployment he began to develop more neck pain.  The cervical spine MRI demonstrated mild dessication and disc space narrowing at C3-4 and C5-6 and DDD.  The primary care provider (PCP) documented that the CI reported tenderness to palpation (TTP) at C3-4.  There were physical exam findings of TTP of the spinous processes, C3 spinous process TTP; C4 spinous process TTP which radiated from the left side of the neck to the left temple of the face.  The PCP documented muscle stiffness and pain on the right side of the shoulder to the back of the neck.  The physical exam findings were numbness, TTP from the right shoulder bade to the right side of the neck with muscle tightness.  The pain clinic specialist noted that the CI reported sharp, shooting neck pain that started behind the ear on the left side and it stayed on the left side of the head and to the eyeball which caused nausea.  The examiner scheduled a left occipital nerve block.  The commander’s statement indicated that the CI’s profile prevented him from performing his MOS and rendered him non-deployable.  The MEB Addendum exam completed approximately 10 half months prior to separation documented that the CI had pain in the posterior scalp with paresthesia that covered the occipital nerve on the left.  The CI also had significant pain in the left upper and mid trapezius region.  There was no physical exam performed at this exam.  The MEB NARSUM exam approximately 9 months prior to separation documented that the neck pain was primarily on the left upper and mid trapezius region.  The dull burning sensation neck pain ranged from 3/10 to 8/10 and was aggravated with any type of vigorous activity.  The cervical spine MRI demonstrated a small posterior protrusion at C6-7 indenting the ventral surface of the spinal cord and mild multilevel degenerative changes with associated foraminal narrowing.  The CI was given a permanent U3 profile for cervical degenerative disease (neck pain) and another medical condition, with a Code C and specific restrictions noted on the profile.  The VA C&P exam approximately 2 months prior to separation documented that the CI reported that flare-ups include cold, damp weather caused the pain to radiate down to the back of the arms particularly the left side.  The CI underwent trigger point injections which gave him pain relief for 2 weeks.  The VA C&P physical exam findings are summarized in the chart below.

There were two ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Cervical ROM (Degrees)	MEB ~9 Mos. Pre-Sep	VA C&P ~2 Mos. Pre-Sep	
Flex (45 Normal)	45	55 (45)	
Combined (340)	250	210	
Comments	Pos. painful motion; Normal motor, sensory & reflexes; Pos. tenderness to palpation	Pos. painful motion & spasm; No Deluca criteria; Normal neurological exam	
§4.71a Rating	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the chronic neck pain condition as 5299 analogous to 5243 (intervertebral disc syndrome) and rated at 10%.  The VA coded the DDD-Cervical Spine condition as 5242 (degenerative arthritis of the spine) and rated at 10%.  The General Rating Formula for Diseases and Injuries of the Spine considers the CI’s pain symptoms “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.”  The CI met the 10% rating criteria for “combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees.”  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 chronic neck pain condition.

Contended PEB Conditions.  The contended conditions adjudicated as not unfitting by the PEB were occipital neuralgia, cluster headaches, nightmare disorder, panic disorder (CI contended PTSD) and enthesopathy.  The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  None of these conditions (and no mental health condition regardless of diagnosis) was profiled; the CI was only profiled for the neck and low back conditions.  None of these conditions were implicated in the commander’s statement; and, none were judged to fail retention standards.  All were reviewed by the action officer and considered by the Board.  There was no indication from the record that any of these conditions 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 occipital neuralgia, cluster headaches, nightmare disorder, panic disorder (contended PTSD by the CI) and enthesopathy contended conditions and, therefore, no additional disability ratings can be recommended.

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 thoracolumbar spine pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic neck pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended occipital neuralgia, cluster headaches, nightmare disorder, panic disorder/PTSD and enthesopathy conditions, 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.

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 20140429, 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, AR20150013462 (PD201401525)

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)