RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01907
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20050411

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E5, Motor Transport Operator, medically separated for “chronic neck pain” and “occipital neuralgia with headaches,” rated 10% and 10% respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI contends the following conditions: cervical spondylosis with degenerative disc disease, post-traumatic stress disorder (PTSD), traumatic brain injury (TBI) and type II diabetes mellitus.  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 based upon a 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 - 20050314	VARD - 20060227	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5242	10%	Degenerative Disc Disease, Cervical Spine (Claimed as Neck Pain)	5237	10%	20051101	
Occipital Neuralgia with Headaches	5242-8405	10%	Occipital Neuralgia	8100	0%		
Depressive Disorder	Not Unfitting	Depressive Disorder/Anxiety
Disorder/Post-Traumatic Stress Disorder with Nightmares	9434-9411	NSC	STR	
Anxiety Disorder	Not Unfitting					
Poor Sleep with Nightmares	Not Unfitting					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Neck Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s non-trauma related chronic neck pain condition began while deployed to Iraq in February 2003.  Radiological studies in August 2004 showed loss of cervical lordosis, severe cervical spondylosis with degenerative changes of C3-C7 with narrowing of the disk spaces, and hypertrophy of the uncovertebral process at C3-C7.  MRI studies showed multi-level spondylosis and degenerative disk disease.  Electrodiagnostic studies performed in August 2004 were normal without evidence of left cervical radiculopathy or ulnar neuropathy.  There was no surgical indication.  Despite treatment the cervical spine condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic neck and shoulder pain with significant degenerative changes to the cervicalgia” and “left occipital neuralgia” for PEB adjudication.  

The MEB NARSUM examination on 18 January 2005, 3 months prior to separation, noted complaints of constant upper trapezius and cervical pain, worse with activities.  The physical examination showed multiple tender areas and trigger points.  The range of motion (ROM) documented at the physical therapy (PT) ROM examination 4 months prior to separation recorded cervical flexion to 10 degrees (normal is 45) and extension to 15 degrees (45).  The ROM testing documented at the neurology examination 3 days after the PT ROM examination, recorded full ROM in the cervical spine.  

At the 1 November 2005 VA Compensation and Pension (C&P) evaluation, performed 7 months after separation, the CI reported  that he had been suffering from degenerative disk disease for 2 years.  The pain was described as constant, localized, aching and elicited by physical activity.  The pain was relieved by rest and medication.  The CI stated that his condition did not cause incapacitation, no functional impairment and no lost time from work.  The physical examination showed no evidence of radiating pain on movement, no spasms, no tenderness, no ankylosis of the spine, and no signs of intervertebral disc syndrome.  The ROM flexion of the cervical spine was recorded as 35 degrees.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic neck pain condition 10% coded 5242 (degenerative arthritis of the spine), citing limitation of motion and rated for tenderness.  The VA also assigned a 10% rating using 5237 (cervical spine strain), citing limitation of motion by pain with a forward flexion and extension to 35 degrees.  

The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 40 degrees) and/or combined ROM (greater than 170 degrees but not greater than 335 degrees) reported on the Neurology and VA C&P examinations, proximate to separation.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  The Board noted the limitation of cervical spine motion recorded in the MEB NARSUM (PT) examination met the threshold for a 30% rating; however, the Board noted the neurology and VA examinations proximate to separation, had greater clinical detail and supported the 10% rating.  Therefore the Board placed greater probative value on these two examinations.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  There was no associated radiculopathy noted to constitute a separate peripheral nerve rating.  While the CI may have experienced radiating pain from the neck condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairments such as weakness with a direct impact on fitness that were separately functionally impairing for duty.  There was no evidence of cervical spine nerve root involvement by the electrodiagnostic studies conducted August 2004.  The Board therefore concluded that additional disability rating was not justified on this basis.  

After due deliberation, and 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.  

Occipital Neuralgia with Headaches  

 According to the STR and MEB NARSUM, the CI’s headache condition began in deployment without a history of head trauma.  Despite treatment, the headache condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “left occipital neuralgia, migraine headache and chronic cervicalgia” for PEB adjudication.  

On 13 December 2004 at the neurological examination, the CI reported having severe headaches since June 2004.  He noted that he was assigned to clean out an area of sheep feces during his deployment and his headaches began in association with that task.  Since then, he has had frequent headaches, located behind the left eye.  His headaches occurred 2-3 times a week and were always left sided.  At times he used medication to treat them and at other times he would “ride them out” and treat them with rest.  The neurologist assessed left occipital neuralgia (left sided head pain), and migraine headache, without aura, with precipitating factors, to include: occipital neuralgia.  Prostrating headaches were not described.  

At the MEB NARSUM exam dated 18 January 2005, 3 months prior to separation, the CI reported he had 2-3 headaches a week prior to receiving nerve block treatment which resolved his headaches for a few weeks post injection.  He then continued to have weekly headaches.  

At the VA C&P examination in November 2005, performed 7 months after separation, the CI reported reoccurring headaches which had not interfered with work, but required medication.  He noted that there was no functional impairment resulting from headaches and he had not lost any time from work due to headaches.  The physical exam was unremarkable.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the analogous code 5242-8405 (degenerative arthritis-neuralgia-incomplete, moderate).  The VA assigned a 0% rating under the migraine headache code of 8100 for the condition occipital neuralgia.  The Board considered the evidence and all Board members agreed the 8100 code best reflected the CI’s headache condition; however, the Board concluded the use of this code provided no additional benefits to the CI.  The Board agreed that a 10% rating, but no higher, was justified for the headache condition under the nerve code 8405, and there was no justification for a higher rating under the 8100 code since prostrating attacks were not present.  There were no additional applicable codes to consider for rating the condition.

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 headache condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the depressive disorder, anxiety disorder and poor sleep with nightmares conditions were not unfitting.  The mental health conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  There was no performance-based evidence from the record that any mental health condition, regardless of diagnosis, significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  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 occipital neuralgia with headaches condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended depressive disorder, anxiety disorder and poor sleep with nightmares conditions, the Board 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 20141115, 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 AR20160011762 (PD201401907)

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