RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01573
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080612

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Automated Logistics Specialist, medically separated for “L5-S1 fusion following lumbar laminectomy…no neurologic deficits,” with a disability rating of 20%.

CI CONTENTION:  The CI specifically contended for PTSD.  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.  

RATING COMPARISON:  

SERVICE PEB - 20080310	VARD - 20081108	
Condition	Code	Rating	Condition	Code	Rating	Exam	
L5-S1 Fusion…No Neurologic Deficits	5241	20%	Residuals, Lumbar Spine Diskectomy	5241	20%	20080806	
Episodic Mood Disorder	Not Unfitting	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Lumbosacral Spine Condition.  Pursuant to remote spine injuries the CI underwent an L5-S1 spinal fusion in February 2007.  Despite aggressive post-operative rehabilitation, he remained with low back pain (LBP), occasional spasm, and intermittent altered sensation into both lower extremities.  He was permanently profiled in August 2007 and referred to a Medical Evaluation Board (MEB).  At the MEB narrative summary (NARSUM) examination (10 December 2007; 6 months prior to separation), the CI’s chief complaint remained LBP.  The physical examination (PE) noted low back tenderness with spasm.  His pain was assessed as ‘moderate and intermittent to frequent’ and his diagnosis was lumbar DDD status-post surgical fusion.  The NARSUM also referred to spinal motion measurement using non-goniometric techniques.  At the VA Compensation and Pension (C&P) examination (06 August 2008; 2 months after separation), the CI reported constant LBP with flare-ups aggravated by prolonged walking, standing and sitting in one position (driving).  His symptoms were alleviated with rest, pain medication, or changing positions.  Additionally, he endorsed a shooting pain into his left leg during flare-ups.  His PE revealed thoracolumbar tenderness as well as decreased and painful range-of-motion (ROM).  His gait was altered with a left-sided limp.  There was an unquantified sensory deficit in his left foot and a slight (4/5) weakness in his left lower extremity.  His diagnosis was noted as moderate residuals of lumbar spine discectomy and fusion.  

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA coded the back condition 5241 (spinal fusion) at 20% citing the presence of tenderness and or limited motion.  Board members first deliberated and agreed that the greatest of examination probative value be given to the VA evaluation based upon the nearer time reference to separation as well as the non-current VASRD practice of using an inclinometer to measure ROM at the pre-separation PT examination.  The Board agreed that the probative examination clearly supported no greater than 20% impairment.  Members then considered and deliberated whether a separately ratable condition of a neuropathy/radiculopathy existed with functional impairment linked to fitness near the time of separation due to his complaint of left leg symptoms.  Members concluded that despite having subjective complaints of a shooting lower extremity pain at the VA examination, the objective evidence of decreased sensation confined to an area below the ankle coupled with the minimalist of weakness did not meet criteria for concluding it was a separately unfitting condition, and therefore, cannot be recommended for additional disability rating.  Additionally, the radicular type pain in this condition is subsumed under the general spine rating as specified in §4.71a.  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 lumbosacral spine condition.

Contended PEB Condition.  

Episodic Mood Disorder.  The mood disorder was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  The condition was reviewed and considered by the Board.  Members acknowledged that the first manifested active symptoms of a mental health condition were diagnosed in February 2009 (p 664); 8 months after separation.  The single service-related clinical encounter that brought up a mood condition was dated 19 December 2007 which stated, “The [CI] has a history of episodic mood disturbance, but it is EPTS (existed prior to enlistment) and medically acceptable for MEB purposes.”  Additionally, he admitted nothing from a mental health perspective had affected his work.  Board members agreed that 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 episodic mood disorder and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the lumbosacral spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended episodic mood disorder, 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 20140402, 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 AR20i 60006755 (PD201401573)

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