RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01980
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050523

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Signals Intelligence Analysis, medically separated for “compression fracture L1 vertebra,” with a disability rating of 10%.  

CI CONTENTION:  The applicant makes no specific contention in their application.  The applicant’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 - 20050406	VARD – 20050825	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Compression Fracture L1 Vertebra	5235	10%	Residuals L1 Fracture	5299-5235	40%	20050802/11	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Compression Fracture L1 Vertebra.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI sustained a compression fracture (fx) of the L1 vertebra in July 2003 during an all-terrain vehicle accident.  Radiographic studies showed a L1 vertebral body compression fx with some posterior protrusion.  Surgical options were reviewed but the consensus of three surgical opinions was for a trial of external bracing.  At follow-up visit on 4 September 2003, the CI reported improvement with the brace, physical therapy, medications, and rest.  She reported she had traveled by car with her husband to his duty station (approximately 1200 miles).  The examination noted the CI was able to ambulate without pain or difficulty.  It was decided that she could drive to a new duty station after convalescent leave as she requested, also about 1,200 miles distance, with use of her back brace at all times.

At the time of the orthopedic spine clinic appointment on 21 October 2003 (following her relocation), performed 19 months before separation, the CI reported her back pain had significantly improved, but she still had low back pain (LBP) and fatigue after approximately 15 minutes out of her brace.  She denied lower extremity (LE) symptoms.  The examiner indicated that the patient stated when she flexed forward she had increased LBP and occasionally some paresthesias in bilateral feet.  The orthopedic surgeon noted that he and the CI agreed that surgical intervention was not indicated at the time.

At an emergency room visit on 22 March 2004 the CI reported increased back pain following chiropractic manipulation.  The physical examination noted the CI was in no acute distress (NAD) and ambulated without difficulty and back range-of-motion (ROM) was performed with “mild pain”.  Repeat thoracolumbar (TL) X-rays were ordered and the CI was referred back to orthopedics for follow-up.  At the orthopedic follow-up visit a few days later, the CI was noted to be in NAD and there was “some” tenderness to palpation of the muscles around the L1 vertebra.  The orthopedic surgeon indicated there was no change in the alignment of the spine noted on the X-rays.  The CI was recommended to continue with back and abdominal stretching and strengthening exercise and to use anti-inflammatory medication as needed and was placed on 48 hours quarters.  

During an orthopedic spine clinic appointment on 11 June 2004, performed 12 months before separation, the CI reported she felt pain and discomfort within an hour of awakening and the pain persisted while upright and was relieved by lying down.  She denied any radiating numbness, tingling or weakness in the bilateral LE.  On examination there was tenderness at approximately the L1 spinous process in the midline with a “palpable prominence.”  Motor strength and reflexes were normal.  She had a full ROM with “minor tightness” and midline pain at the level of her injury.  LE strength and reflexes were normal.  Possible surgical options were discussed pending a bone scan to determine if the fracture was healed.  The CI indicated she was not interested in more complicated surgical procedures, but would consider lesser procedures if indicated.  

Despite treatment, the back 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 “L1 vertebral body compression fracture (sic)” for PEB adjudication.  

The MEB NARSUM examination on 26 July 2004 (10 months prior to separation) cited the same symptoms and findings as the orthopedic evaluation on 11 June 2004 summarized above.  No mention was made of the results of the bone scan noted at the June orthopedic visit.

In August 2004, the CI reported back pain and that she was out of her pain medication.  The examination noted only the CI was “in some distress.”  She was provided prescriptions for anti-inflammatory and pain medications and the CI was given 48 hours quarters.  At an acute clinic visit for back pain on 20 September 2004, the CI reported she was not wearing her brace or doing any exercises.  She was referred to pain clinic, physical therapy (PT), and advised to wear the brace 6 to 8 hours per day.  On 1 November 2004, the CI was seen for back pain and reported her current medications were not helping.  She was provided new prescriptions of her old medications and an additional daily pain medication was added; she was given 72 hours of quarters.  At a primary care visit on 16 November 2004, the examiner noted “client has hx [history] of medicinal abuse [with] Vicodin (opioid pain medication)”, and the CI was encouraged to consider alternatives and referred for continued PT.

During a pain medicine (PM) clinic appointment on 13 December 2004, performed 5 months before separation, the CI reported back pain, graded 3/10, in the lumbosacral region exacerbated by activity, walking, standing which had worsened over the past 6 months.  Additionally, the CI complained of a tingling sensation and pain in her lower right back radiating to the back of her knees and sharp, shooting, non-radiating pain in the lumbar region.  On examination there was tenderness to palpation of all spinal levels from T10 to L5, buttocks muscles and positive facet loading on the left.  Back flexion (normal 90 degrees) and extension (normal 30 degrees) were noted to be 20 degrees each.  The CI’s oral pain medications had been stopped and she had been prescribed a long acting opioid pain patch.  The dose of the pain patch was increased and an antidepressant medication for chronic pain was prescribed.

At an emergency room visit on 2 January 2005, 2 weeks later, the CI reported increased back pain since moving a box the day before.  Back X-rays were performed.  The CI was treated for pain with injectable anti-inflammatory medication and was not given medications which could cause drowsiness since she was noted to be driving herself and she was given 24 hours quarters.

At the time of an orthopedic clinic appointment on 1 February 2005 (with a second orthopedic surgeon), performed 4 months before separation, the CI reported that she continued to have pain which was worse with activity.  She denied any bowel or bladder symptoms.  On examination she was in NAD with a normal gait and normal strength (iliopsoas, quadriceps, hamstrings, tibialis anterior, extensor hallucis longus, peroneals, and gastrocnemius, soleus).  The examination did not address ROM.  Surgical options were reviewed and the examiner indicated that the CI was pending separation from the military the next day and would consider surgical options after separation.

At a follow-up PM clinic the CI reported that she had obtained significant pain control with the pain patch, grading pain level with it at 2/10.  She had tried to stop the medications due to concern over their chronic use, with increased symptom and the pain patch was restarted at the lower dose.  At the visit the CI reported pain graded 4/10 and the examination noted only that the CI was in NAD.  The PM specialist restarted the antidepressant medication and increased the dose of the pain patch.

At the VA Compensation and Pension (C&P) spine examination on 3 August 2005 performed 2 months after separation, the CI reported daily chronic LBP which radiated into both LEs to the knees, with some associated numbness in the left leg, without bowel or bladder problems.  She reported she did have a bone scan and X-rays and the VA examiner indicated the X-rays showed “L1 healing.”  She reported that she did not use a cane or crutches, occasionally used a wheelchair, and wore a hard back brace every day.  Additionally, the CI reported eight incapacitating episodes in the past year.  She reported she did have a bone scan and X-rays and the examiner indicated the X-rays showed “L1 healing.”  The examiner noted the CI was wearing a hard back brace which she kept on during the examination and it was difficult to examine her with the brace.  The physical examination showed back ROM of forward flexion of 30 degrees (90 degrees normal) with a combined ROM of 110 degrees (240 degrees normal) with painful motion in all planes.  Active ROM did not produce any weakness fatigue or incoordination.  LE strength, sensation, and reflexes were normal. Lumbar spine X-rays noted a “moderate” wedge shaped compression fx of the L1 vertebra, without other vertebral fxs, and with maintained intervertebral spaces.  A remote VA C&P examination performed on 17 March 2008, 34 months after separation, noted that a recent magnetic resonance imaging showed a 50 percent compression fracture of L1, which was healed and stable.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the compression fracture L1 vertebra condition 10% coded 5235 (vertebral fracture or dislocation).  The VA rated the residuals, L1 fracture condition 40% coded analogous to 5235 (vertebral fracture or dislocation), based on the VA C&P examination 2 months after separation, citing incapacitating episodes of intervertebral disc syndrome.  

The Board agreed that a 10% rating of the back condition was supported by the criteria of “muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height.”  The Board carefully considered if a higher rating was supported by the evidence in record.  The MEB NARSUM examination was performed by an orthopedic surgeon and was performed on 11 June 2004 and the NARSUM was written in July 2004 by the same orthopedic specialist, with no change in the status of the back condition noted, approximately a year after the fx had occurred.  The MEB NARSUM examination indicated full back ROM with focal midline pain and “minor tightness’ of muscles at the level of the fx.  The Board interpreted this description of the CI’s ROM as reflecting TL ROM within functional limits.  This contention is supported by the second orthopedic opinion in February 2005.  No ROM of the TL spine was documented at that visit, but the examiner documented thorough muscle strength evaluation, including of the iliopsoas muscle, a hip flexor that has its origins from the upper lumbar spine, with normal strength of all muscles noted and no particular difficulty with pain or muscle spasm during strength testing was documented.  At the post-separation C&P examination the CI’s ROM was recorded as much worse, but the CI had a rigid back brace on and it remained in place during the examinaiton.  The Board consensus was that TL ROM obtained while in a brace designed to restrict ROM was not useful for the purpose of providing a rating according to the VASRD and, therefore Members placed greater probative value on the orthopedic exams in June 2004 and February 2005 for its rating recommendation.  The evidence in record indicated that the CI was able to ambulate normally with or without the brace and was noted to have full ROM, with aggravation of back pain by activity.  Therefore, based on ROM criteria, the Board concluded that a higher rating than 10% was not warranted.  The final orthopedic note in record indicated continued discussion of possible surgical intervention at the time of separation.  However, no post-separation visits with a surgeon for treatment or further discussion of surgical options are in record, and no surgery occurred after separation based on VA Rating Decisions as of September 2011.  

At the C&P examination the CI reported eight incapacitating episodes in the past year.  There were periods of quarters documented in the STR in the 14 months before separation with a total duration of eight days.  The Board notes that periods of quarters are not necessarily equivalent to incapacitating specified by the VASRD to require “bed rest prescribed by a physician.”  However, even if conceded as equivalent to incapacitating episodes in this case, there is no documentation of incapacitating episodes “with a total duration of at least 2 weeks in the past 12 months” to support a higher rating under the alternate VASRD formula for rating the spine.  

The CI reported radiating pain and some numbness and tingling of the LEs, but all exams in record noted normal strength and sensation of the LEs.  Radiating pain is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates), and there was no objective evidence of a radiculopathy that was separately functionally impairing for duty.  The Board therefore concluded that 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 lumbar vertebral compression fx condition.  

BOARD FINDINGS:  In the matter of the “compression fracture L1 vertebra” condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20131119, 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-2014-01980.

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