RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01690
BRANCH OF SERVICE:  Coast Guard	BOARD DATE:  20150512
SEPARATION DATE:  20080911

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Coast Guard Reserve E-6 (Operations Specialist) medically separated for a back condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Rating or satisfy physical fitness standards.  He was placed on limited duty and referred for a Medical Evaluation Board (MEB).  The “lumbago” condition was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other conditions were submitted by the MEB.  The Informal PEB (IPEB) adjudicated “degenerative arthritis of the thoracolumbar spine” as unfitting, rated 10%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  After an appeal to the Formal PEB (FPEB), which changed the rating to 20%, the CI was medically separated.

CI CONTENTION:  His condition continues 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, 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 FPEB – Dated 20080304	VA* – ~24 Mos. Post-Separation 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Arthritis of the Thoracolumbar Spine	5242	20%	DDD of the Lumbar Spine w/Radiating Pain to Both Lower Extremities (Hips and Legs)	5243	10%	20100907	
Other x 0 (Not in Scope)	Other x 5	
RATING:  20%	COMBINED RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20111108 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Degenerative Arthritis of the Thoracolumbar Spine Condition.  The first note in the service treatment record dated 1 November 2006 indicated the CI had a follow-up visit for ongoing stabbing, sharp pain in the back while lying down, with occasional shooting pain down both legs.  He had palpable spasms and trigger points in the iliolumbar (lower back) region bilaterally.  Range-of-motion (ROM) was 100% normal, while extension, rotation bilaterally, and lateral bending bilaterally were 60% normal.  There were positive facet maneuvers (suggesting changes secondary to osteoarthritis).  A special mattress and bed were recommended along with exercises for lumbar stabilization.  A note dated 12 December 2006, indicated the CI had a significant fall on his back while snowboarding in 2000; later he thought it was in 1997.  The CI experienced a flare-up with deployment in 2003 and as a result of running before and after his most recent deployment.  Treatment consisted of Mobic (meloxicam - a nonsteroidal anti-inflammatory medication) and Ultram (tramadol - an opioid-like pain medication).  X-rays of the lumbar spine were negative on 14 December 2006.  Several magnetic resonance images (MRI) dated 15 December 2006, revealed degenerative disc disease (DDD) of the mid- to distal-thoracic spine with small protrusions at T4-5 and T8-9 and multilevel DDD with minimal retrolisthesis (backward displacement of a vertebral body on another) resulting in mild to moderate canal stenosis and neural foraminal (site of exiting nerves from the spinal cord) narrowing.  In January 2007, a physical medicine and rehabilitation (PM&R) consultant advised discontinuation of Mobic, use of a firm mattress and therapeutic exercises to improve lumbar stabilization and ROM as well as to improve overall flexibility, strength, and endurance.  An X-ray series dated 8 January 2007 confirmed Grade I retrolisthesis of L5 on S1 and mild disc space narrowing at L5-S1.  There was no significant electrodiagnostic evidence for a lumbosacral radiculopathy.  On 8 February 2007, the PM&R specialist noted palpable spasms and trigger points in the iliolumbar region bilaterally and the ROM of the lumbar spine was 100% normal in all planes.  By 8 March 2007, lumbar strain was slowly resolving although stabbing, sharp pain in the low back persisted and the facet maneuver was positive.  On 29 March 2007, a pain management consultant assessed the CI’s condition as a facet syndrome (arthritic changes) and recommended a facet steroid injection to help alleviate the CI’s pain and his reliance on medication; Cymbalta (duloxetine) was prescribed to alleviate nerve pain.  Lumbar facet steroid injections were carried out on 11 April 2007 and 25 April 2007.  An MRI of the lumbar spine dated 7 May 2007, showed DDD, facet arthropathy, moderate canal stenosis, moderate foraminal narrowing and a small left lateral protrusion at L4-5.  Thoracic outlet compression maneuvers were normal in May 2007.  PM&R follow-up on 14 May 2007 indicated chronic lumbar discogenic pain with radiculitis.  The CI was not a surgical candidate, which was confirmed by a neurosurgeon.  Pain management continued and included discontinuing Kadian (morphine extended release) and using lidocaine/ketamine anesthetic cream; the CI was also given a prescription for Norco (acetaminophen - a pain reliever and hydrocodone - a narcotic).  A note dated 14 December 2007, indicated the CI had a medical board and he felt stressed about his future.  Gabapentin (for nerve pain) was added to the medication protocol.  In February 2008, the CI had a flare-up of back pain and stiffness with pain radiating down the left leg and right hip.  Forward flexion was 15 degrees.  Skelaxin (metaxalone - a muscle relaxant) was added for myofascial pain syndrome, chronic pain caused by multiple trigger points and fascial (connective tissue covering muscle) constrictions; Cymbalta was continued for depression.  The pain management consultant opined on 5 May 2008 that the CI had intermittent leg pain over the years and that it was possible that with minimal movement at the L4 and L5 levels there could be some dynamic compression and nerve root irritation at times.  However, he believed the majority of the CI’s pain was facet-related as well as myofascial and he would likely benefit from facet joint injections and possible pulsed radiofrequency ablation.  On 2 June 2008, the CI underwent bilateral lumbar medial branch blocks at L3-S1 without any relief.  X-rays of the hips revealed well-preserved joint spaces with some corticated ossicles (small bones) adjacent to each acetabulum (socket of the hip joint), which were developmental, degenerative, or post-traumatic. Relafen (nabumetone - a nonsteroidal anti-inflammatory medication) was added and the CI felt it helped his back pain.  On 10 September 2008, the CI felt better overall with Cymbalta and the nabumetone, but pain of the right hip and leg increased with walking more than an hour and with sitting.  There was no report or evidence of incapacitation.

On the DD Form 2807, Report of Medical History, for the MEB examination, dated 8 April 2008, the CI noted “pain associated with L5-S1 slippage and chronic nerve pain” and “numbness and tingling in feet and hands when in severe back pain.”  The MEB physical examination noted the ROM was fingertips to knees.  Extension was 20% of normal and the rest of the ROMs were normal.  Straight leg raising (SLR) was normal; Lasegue’s test (a two-part test of SLR, the second part with the knee flexed) was negative; and the FABER test (to determine hip, lumbar and sacroiliac pathology) was also negative.  There was tenderness over the entire sacral area below L5.  The CI was able to walk on heels and toes well and, neurologically, the lower extremities were intact bilaterally.

The MEB narrative summary dated 27 February 2009, noted the CI spontaneously developed low back pain (LBP) in April 2006 in the absence of a precipitating injury.  Within a few months he experienced occasional momentary shooting pains down both legs without numbness, weakness, or bowel/bladder symptoms.  The ROM at that time was reduced due to pain, but neurological examinations were normal.  Imaging studies did not reveal a herniated disc or other surgically correctable lesions. A study of the muscles using an electromyogram (EMG) was normal.  Treatment consisted of physical therapy, Lidoderm patch (lidocaine - an anesthetic), lumbar steroid injections, and medication.  Physical examination showed a slow but normal gait and a slow squat with rising without difficulty.  He was able to stand on his tip-toes and heels without difficulty.  Back flexion was 40 degrees (slowly, painfully), extension 15 degrees, lateral flexion 20 degrees left and right, and rotation 30 degrees left and right.  Lower extremity reflexes, strength and sensation were normal and single leg raises (to determine nerve root irritation) were negative.  The CI was available only for limited duty—no boat or sea duty, no prolonged standing or sitting, no climbing or heavy lifting with work hours as tolerated; his prognosis was extremely poor.

At a pain management visit on 5 February 2009, almost 5 months after separation, the CI reported the LBP improved with chiropractic adjustments and he was off all narcotics.  A lumbar spine series dated 1 April 2009, revealed scoliosis with disc degeneration and facet arthropathy.  An MRI dated 17 December 2009, 14 months after separation, revealed congenital spinal stenosis with moderate spinal stenosis at L3-4 and L4-5 and mild spinal stenosis at L1-2 and L2-3.  There was a superimposed left foraminal disc protrusion at L2-3 without evidence of nerve root compression.

At the VA Compensation and Pension (C&P) examination, dated 7 September 2010 and performed 24 months after separation, the CI reported that back pain began in 2003 with radiation towards his hips and to the left legs worse on the right than the left.  He took etodolac (a nonsteroidal anti-inflammatory medication), Neurontin (gabapentin - for nerve pain), and Lyrica (pregabalin - for nerve pain) for back pain and used a brace for lifting.  Neurologic examination was unremarkable, SLR was limited to 60 degrees and Lasegue’s signs were negative.  His gait was very antalgic with obvious pain.  The VA examiner’s diagnosis was moderately symptomatic DDD of the lumbar spine involving L4-L5 and L5-S1 with slight left scoliosis.

The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)	MEB ~ 07 Mo. Pre-Sep	VA C&P ~ 24 Mo. Post-Sep	
Flexion (90 Normal)	40	90	
Extension (30)	15	10	
R Lat Flexion (30)	20	15	
L Lat Flexion (30)	20	15	
R Rotation (30)	30	-	
L Rotation (30)	30	-	
Combined (240)	155		
Comment	Slow, but normal gait	Refused to perform right and left rotation; no change in measurements after three repetitions; antalgic gait; slight left scoliosis	
§4.71a Rating	20%	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The Coast Guard FPEB assigned a 20% rating using VASRD code 5242 for degenerative arthritis of the thoracolumbar spine.  The VA assigned a 10% rating using code 5243 for DDD of the lumbar spine with radiating pain to both lower extremities (hips and legs).  The Board considered whether an additional rating could be recommended under a peripheral nerve code.  Firm Board precedence requires a functional impairment linked to fitness to support a recommendation for addition of a peripheral nerve rating to disability in spine conditions.  Although the pain component of the neuropathy is appropriately subsumed in the spine rating IAW VASRD §4.71, which states that “rating is performed 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 sensory component had limited functional implications, and no motor weakness was in evidence.  Therefore, the radiculopathy could not be recommended for additional disability rating.  The Board sought a route to a higher rating; however, in the absence of flexion less than 30 degrees or incapacitating episodes proximate to separation, the Board was unable to find any additional or higher rating.  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 degenerative arthritis of the thoracolumbar 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.  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 20140409, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Commandant
United States Coast Guard	Mail Stop 7907
2703 Martin Luther King Jr. Ave SE
Washington, DC 20593-7907
Staff Symbol: CG-1
Phone: (202) 475-5000

								   1850

Dear XXXXXXXXXX
I am the Designated Decision Authority for the Coast Guard on applications submitted to the Department of Defense Physical Disability Board of Review (PDBR).  Under the authority of Title 10, United States Code, section 1554a, I accept the PDBR’s recommendation in your case (Case Number PD-2014-016901) and decline to modify your findings. 

Enclosed for your information are a copy of the PDBR’s recommendation and a copy of the record of proceedings. 

A copy of this decision has also been provided to Coast Guard Enlisted Personnel Management Branch, the PDBR, and the Department of Veterans Affairs. 

If you have any further questions, please contact the Coast Guard Personnel Service Center at (703) 872-6628. 
	Sincerely,

2 Enclosures		
	
Copy:	CG Personnel Service Center (EPM-1)
DoD Physical Disability Board of Review
Department of Veterans Affairs