RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02223
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20021126

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Information Systems Technician) medically separated for lumbar degenerative disc disease.  The condition could not be adequately rehabilitated to meet the physical requirements of her Rating.  She was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The “lumbar degenerative disease”, “low back pain” and “epidural fibrosis,” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The Informal PEB (IPEB) adjudicated “lumbar degenerative disc disease” as unfitting, rated 20% citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting/Category II, (contributing to unfitting condition).  The IPEB also determined an additional condition, “migraine headaches” to be not unfitting/Category III (not separately unfitting and do not contribute to the unfitting condition).  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI requested that the Board review all of her conditions.  The 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:  

IPEB – Dated 20021025	VA* - (~48 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar Degenerative Disc Disease	5293-8520	20%	Degenerative Disc Disease, L5-S1 with Residuals	5243	20%	20061127	
Low Back Pain	Not Unfitting /Cat II	No VA Placement	
Epidural Fibrosis		No VA Placement	
Migraine Headaches	Not Unfitting/Cat III	Migraine Headaches	Not Service Connected	20061127	
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 1 	
RATING:  20%	RATING:  20% 	
*Derived from VA Rating Decision (VARD) dated 20070207 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Lumbar Degenerative Disc Disease.  The service treatment record (STR) supplements and supports the MEB narrative summary (NARSUM) dated 7 August 2002.  The earliest note in the STR from 30 June 2000 indicated the CI developed low back pain and right leg pain while playing volleyball.  Right sciatic radicular pain persisted in spite of treatment with physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDS).  An MRI showed an L5-S1 herniated disc eccentric to the right side.  The CI underwent an L5-S1 discectomy on 12 May 2001.  By June 2001, after a fall she had symptoms similar to the preoperative state treated with epidural steroid injections.  Epidural fibrosis (scar tissue around a nerve root) was noted on a postoperative MRI and a follow-up MRI showed a recurrent herniated disc.  She underwent a second L5-S1 discectomy in August 2001.  Initially, she did well, but she had a gradual return of the low back pain and right leg pain after she participated in a medevac, but a follow-up MRI showed no significant herniated disc and treatment with an oral steroid resolved the pain.  Recurrent pain was again treated with an epidural steroid injection (ESI).  She noted back pain and right leg pain after resuming physical training, which did not resolve on discontinuation.  An MRI of the lumbar spine performed in January 2002 revealed postoperative changes at the L5-S1 level.  The L5-S1 disc was degenerated and there was epidural scarring in the region of the surgery along the S1 nerve root on the right side.  There was no evidence of a recurrent disc herniation.  After another ESI In March 2002 her pain resolved, however within two months the pain recurred, and additional ESIs were given with limited, short term relief.  The pain was present in the back, which was worse than the leg where the pain shot down to the toes and was associated with chronic numbness in the medial side mostly in the big toe.  Additionally, her leg gave out on her.  She had no bowel or bladder problems.   Because of the pain, she was unable to run, swim or walk for very long without it increasing.  L5-S1 fusion surgery was discussed, but the CI did not want any further surgery.  The NARSUM examiner noted the CI had a well-healed incision in the lower back with full strength in her left lower extremity but diffuse give way weakness in her right lower extremity and decreased sensation to light touch along the medial side of her right foot.  Flexion was limited due to pain; extension appeared normal.  Reflexes were normal bilaterally in the ankles and knees.  There were no episodes of incapacitation in the STR while the CI was on active duty.

Low Back Pain.  While playing volleyball in June 2000, the CI developed low back pain with a herniated disc, the details and course of which are discussed above.  In spite of two discectomies, physical therapy, medication, and ESIs, the low back pain persisted, which interfered with her ability to walk for very long and limited her physical training.  

Epidural Fibrosis.  In July 2001 two months after a right L5-S1 discectomy was performed the CI had post-operative pain and an examiner’s impression was that she had epidural fibrosis on an initial postop MRI scan.  Treatment consisted of ESIs.  As addressed above an MRI in January 2002 showed postoperative changes with disc degeneration and epidural scarring in the region of surgery along the S1 nerve root on the right side, while in April and June 2002 the STR notes indicated that after the second L5-S1 discectomy, the CI had recurrent pain and an MRI scan showed significant epidural fibrosis, which was again treated with ESIs.

At the MEB examination dated 8 August 2002, the CI reported a herniated disc at L5-S1, while on 23 August 2002, the MEB physical examiner noted “decreased lumbar flexion/rotation, a surgical scar, weakness +4/5 of the right lower extremity and decreased sensation of the medial right foot.”  The non-medical assessment (NMA) dated 8 August 2002 indicated the CI had not been in a full duty status since April 2001 and had been absent from command duties 15 hours per week, although she was capable as an IT (information technologist) of performing normal duties, which were normally carried out in an office environment without any prolonged standing or strenuous physical activities.  However, due to her physical condition and associated medications she was not able to deploy or to perform collateral duties and her physical condition prevented her from participating in physical fitness events.  It was the NMA opinion that the CI suffered from back pain, which when not in pain, the CI could perform her duties.  No limited duty documents were in the STR but the NARSUM indicated that the CI was on limited duty for approximately 16 months; and, because of pain, she was unable to run or swim or walk for very long without increasing her pain.

At the remote VA Compensation and Pension (C&P) examination dated 27 November 2006, performed 48 months after separation, the CI reported she hurt her lumbar spine in a fall playing sports during PT training in July 2000.  She noted constant, sharp, moderate pain in the lower lumbar area without radiation.  Flare-ups occurred weekly.  She used a cane and was able to walk 1/4-mile.  There was no spasm, guarding, pain with motion, tenderness or weakness.   The thoracolumbar spine range-of-motion (ROM) measurement for flexion was 50 degrees with pain on active motion, but no loss of motion on repetitive use.  Extension was 25 degrees; right and left lateral flexion were 40 degrees each; and right and left lateral rotation were 35 degrees each.  The neurologic examination was unremarkable.

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 ~4 Mo. Pre-Sep
	VA C&P ~48 Mo. Post-Sep
	
Flexion (90 Normal)	Limited	0-50*	
Extension (30)	Normal	0-25	
R Lat Flexion (30)	-	(30)0-40	
L Lat Flexion (30)	-	(30)0-40	
R Rotation (30)	-	(30)0-35	
L Rotation (30)	-	30)0-35	
Combined (240)	-	195	
Comment	Full strength LLE; give way weakness RLE with strength 4+/5; decreased sensation to light touch along the right foot medially; epidural scarring along the S1 nerve root on the right side.	*Pain on motion	
§4.71a Rating	(PEB 10%)	20%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5293 (Intervertebral disc syndrome) and a 10% rating using code 8520 (sciatic nerve-mild incomplete paralysis) for the Category I condition lumbar degenerative disc disease.  The VA assigned a 20% rating using the code 5243 (Intervertebral disc syndrome), which was in effect in 2006 rather than a code in effect at the time of separation, for degenerative disc disease of L5-S1 with residuals.  The Board sought a route to a higher rating and noted the PEB used code 5293, which includes symptoms compatible with sciatic neuropathy.  However, instead of a straight 20% rating with code 5293, it separately rated the condition using the aggregate of codes 5293 and 8520.  The Board did note that there was diffuse give way weakness in her right lower extremity and decreased sensation to light touch along the medial side of her right foot, but did not find either clinical sensory or motor components of a radiculopathy to warrant an additional rating for a moderate incomplete paralysis of the sciatic nerve.  The Board also considered a 40% rating using code 5293 for severe, recurring attacks with intermittent relief since she underwent two discectomies and had multiple ESIs, none of which afforded permanent relief, but she was able to perform her IT duties.  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 degenerative disease condition.

The Category II condition of low back pain is related to the Category I condition lumbar degenerative disc disease and is a more general term for the aforementioned condition and is not separately unfitting and not ratable.  Epidural fibrosis was the result of two discectomies   and contributed to the Category I condition pain component and is related to the PEB’s use of code 8520.  It may also be considered to be a residual component of the intervertebral disc syndrome and is not separately unfitting and not ratable.

Contended PEB Condition-Migraine Headaches, Poorly Controlled.  

Migraine Headaches.  The CI was diagnosed with both migraine headaches and tension headaches by a neurologist in May 2001 post L-5/S-1 surgery.  Migraine headache symptoms were marked by band-like pressure, slight nausea, and occasional blurred vision monthly and lasted for 2 weeks duration.  Treatment consisting of Celexa (citalopram, an anti-depressant (SSRI) and Tenormin (atenolol, a beta blocker) initially improved the frequency and severity of the headaches, but they were subsequently worsened by the Tenormin, which was discontinued.  Tension-like headaches were dulled, but not eliminated with Tylenol (acetaminophen, a pain reliever).  The right hand dominant CI had a 1 year history of approximately two headaches per week and had been headache free until March 2002.  The neurosurgical NARSUM dated 26 August 2002 indicated the CI’s headaches were poorly controlled despite adequate trials of three different prophylactic medications (Celexa, Midrin (isometheptene mucate, dichloralphenazone, and acetaminophen) and Maxalt (rizatriptan)), but Fioricet (butalbital, acetaminophen, and caffeine) worked well as an abortive medication, although it induced sleepiness and caused significant interruptions in the CI’s ability to perform her duties.  Examination revealed an alert, oriented woman with fluent speech without dysarthria (unclear articulation).  The remainder of the neurologic examination was unremarkable.  Migraine headaches were treated with Naprosyn (naproxen, an nonsteroidal anti-inflammatory drug) and Phenergan (promethazine, an antihistamine for treatment of nausea or as a sleep aid) at a VA clinic visit in June 2006, while in August 2006, the CI reported the migraine headaches were very well controlled.  No prostrating attacks were reported either in the STR or in VA visits proximate to separation and the VA indicated the migraine headaches were not service connected.

The aforementioned was reviewed and considered by the Board.  There was no performance based evidence in the record that the migraine headaches condition significantly interfered with satisfactory duty performance, although the Fioricet medication did cause drowsiness and sleepiness.  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 migraine headaches condition and so no additional disability rating is 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 lumbar degenerative disc disease condition and IAW VASRD §4.71a and VASRD 4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended migraine headaches condition, 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.  

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 20140514, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 8 Jan 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USN   
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXX, former USN  
- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USN 
- XXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC 

				XXXXXXXXXXXXXXX
	     			Assistant General Counsel
				(Manpower & Reserve Affairs)