RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02284
BRANCH OF SERVICE:  Army	BOARD DATE:  20150624
SEPARATION DATE:  20040525

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Medical Equipment Repairer) medically separated for neck and back pain.  The neck and back conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent U3L3E2 profile and referred for a Medical Evaluation Board (MEB).  “Chronic myofascial neck pain s/p vertebral fracture” and “lumbar spine:  chronic low back pain s/p vertebral fracture” were forwarded by the MEB to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded nine other conditions that did not fall below retention standards (chronic headaches, gastroesphageal reflux, recurrent rosacea, recurrent tinea versicolor, recurrent eczema, hypertension, corneal scar with mild vision defect, elevated cholesterol and median nerve irritability both wrists) for PEB adjudication.  The Informal PEB (IPEB) adjudicated “chronic cervical spine and neck pain following fracture of C6” and “chronic low back pain following fracture of L4-L5” as unfitting, rated 10% and 10%.  The remaining conditions were determined to be not unfitting and therefore not rated.  The CI appealed to the Formal PEB (FPEB) which affirmed the IPEB findings and ratings citing application of AR 635-40.  The CI was medically separated.

CI CONTENTION:  He was not evaluated for shoulder pain, groin pain, chest pain and rib pain.  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 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: 

FPEB – Dated 20040121	VA* - (~1 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Spine and Neck Pain S/P C6 Fracture	5235	10%	S/P Cervical C6 Anterior Inferior Chip Fracture	5237	20%	20040415	

Chronic Low Back Pain S/P Fracture of L4-L5
	5235	10%	Lumbar Spine Compression Fracture with Thoracic Sprain	5237	10%	20040415	
Chronic Headaches w/Cervicogenic and Postconcussive Components	Not Unfitting	Cervicogenic Headaches and Post Concussive Headaches	8045-8100	0%	20040415	
Corneal Scar w/Mild Vision Defect	Not Unfitting	Corneal Scar w/Decreased Vision	6099-6015	0%	20040415	
Other MEB/PEB Conditions x 3 (Not In Scope) 	Other x 16	
COMBINED RATING:  20%	COMBINED RATING:  80%	
*Derived from VA Rating Decision (VARD) dated 20041019 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Neck Condition.  The service treatment record (STR) documents that on 16 October 2002 the CI fell off a roof onto a cement driveway, about 20 feet below.  He was admitted to the Intensive Care Unit and hospitalized for 4 days.  Extensive imaging studies (X-ray, CT) between 16 and 18 October 2002 showed vertebral fractures (right L2, L3, L4, and L5 transverse process fractures and C6 and L4 compression fractures), rib fractures (right 10th and 11th), bilateral scapular fractures, and a pulmonary contusion.  The head CT was unremarkable.  On 31 January 2003, a neurosurgery evaluation documented “He notes that when he flexes his neck he will have some tingling paresthesias [abnormal sensation, tingling, burning, prickling] down his arms, right side of his torso, right leg and on either side of his lumbar paraspinal muscles.  This is not typical for spinal cord symptoms but could be related to this.… His neuroexam remains unremarkable with normal deep tendon reflexes, … biceps, brachioradialis, triceps.…  No pathologic clonus.  No Hoffmann's [reflects presence of upper motor neuron lesion from spinal cord compression].  Motor examination is normal proximally and distally in upper … extremities.  He has a smooth and fluid gait, nonspastic.  He is wearing a soft collar as mentioned today for comfort.”  On 10 March 2003 cervical spine magnetic resonance imaging (MRI) showed no significant central canal, lateral recess, or foraminal (nerve root opening) stenosis (narrowing).  There was a C7 hemangioma (benign tumor formed of excess blood vessels) and a C6 Schmorl's node (protrusion of disc cartilage through vertebral endplate).  The 14 March 2003 neurosurgery follow-up documented “The patient's neuroexam is unremarkable with good strength, normal reflexes, etc.  He still states he has headaches and some neck pain.  When he extends his neck, he will have some lightheadedness.  The patient has some issues with chronic pain … Because of his musculoskeletal myofascial pains, I think an evaluation with a physiatrist would be of benefit with appropriate physical therapy directed and a chronic pain program initiated to deal with this before this should become a problem down the line.  This has been discussed with the patient and films reviewed with him, cervical MRI and flexion/extension xrays.  At this point, I have nothing further to offer from the neurosurgical standpoint and will be ceasing regular follow-up.”  The 29 October 2003 nuclear medicine bone scan showed no abnormal findings.  The narrative summary (NARSUM), 6 months prior to separation, recounted the history and interventions to date.  It documented “His neck pain is more intermittent, and is aggravated by Kevlar, as well as by neck flexion and sleeping wrong.”  The physical exam recorded “There was no tenderness to pressure around the cervical spine but there was palpable spasm of the medial trapezius muscles.”  The 2 December 2003 goniometer measured cervical spine range-of-motions (ROM) (pain limited) are in the chart.  There was normal strength and reflexes and no consistent sensory deficit was found.  The diagnosis was chronic myofascial neck pain status post vertebral fracture, unresponsive to appropriate treatment, and necessitating significant limitation of physical activity.  

The Compensation and Pension (C&P) exam, a month prior to separation, documented “Cervical myofascial pain status post sixth cervical anterior inferior aspect just a chip fracture healed.  To be noted secondary to a fall 15 feet from the roof on October 16, 2002 when it was diagnosed.  Presently regarding the neck, pain is present, but without any brace.  Initially had the Malibu brace put on.  Presently he is able to exercise the neck in all directions.  Only thing is sometimes it gets stiff especially in the lower paraspinals and also in the upper medial aspect of the scapula and sometimes also gets a cervicogenic type of headache.  Pain is present daily and presently not wearing any brace.  Flare-ups can be anywhere from one to eight times a month also.  But there is no evidence of any radiation to the upper extremities or to the interscapular areas or any wrist drop.”  The CI ambulated with a gait where heel strike, foot flat, and takeoff were within normal limits.  The physical exam showed a normal neck with no palpable nodules.  Cervical spine ROMs are listed in the chart.  Three (Deluca) repetitions with resistance did produce a “cervicogenic suboccipital headache and mild lower paraspinal pain radiation especially in the paraspinal and the scapular area … pain reaching 4/10 scale … no radiation of any pain to the upper extremities.”  Upper extremity muscle tone was normal and deep tendon reflexes were present and symmetrical.  There was clinically no evidence of radiculitis (spinal nerve root inflammation).

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

Cervical ROM
(Degrees)	
MEB ~6 Mo. Pre-Sep
	
PT ~5 Mo. Pre-Sep
	
C&P ~ 1 Mo. Pre-Sep
	
Flex (45 Normal)	40 (55,45,40)	45 (45,55,58)	45 dec to 30	
Combined (340)	255	225	340 dec to 260	
Comment	Goniometer		Decrease with DeLuca with Resistance	
§4.71a Rating	10%	10%	 20%	

The Board directed attention to its rating recommendation based on the above evidence.  The FPEB (4 months prior to separation) rated the neck condition at 10%, coded 5235 (vertebral fracture or dislocation).  The PEB cited neck pain following C6 fracture, bulging disc at C6-C7, ROM, muscle spasm, and no radiculopathy (irritation or injury of a nerve root).  The VARD rated the neck condition at 20%, coded 5237 (cervical strain).  The VARD cited pain, flareups, stiffness, ROM, history of C6 vertebral body fracture, C6-C7 broad based disc bulge, and no evidence of radiculitis.  The ROM values in the proximate exams (MEB, PT and C&P) were consistent with the 10% rating.  While the C&P exam reached the threshold for a 20% rating (flexion greater than 15 degrees but not greater than 30 degrees) after repetition, this was in the context of repetition with “resistance,” and therefore was assigned less probative value by the Board.  The neurosurgery and C&P exams documented a normal gait and did not comment of cervical spinal muscle spasm.  The Board agreed a 10% rating was supported based on ROM criterion utilizing the General Rating Formula for Diseases and Injuries of the Spine.  Other routes to a rating higher than a 10% were considered, but there was no evidence of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disk disease.  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 neck condition.

Lower Back Condition.  The STR documents that the CI sustained a low back injury in the 16 October 2002 fall.  The 31 January 2003 neurosurgery evaluation documented “He notes that when he flexes his neck he will have some tingling paresthesias down his arms, right side of his torso, right leg and on either side of his lumbar paraspinal muscles.  This is not typical for spinal cord symptoms but could be related to this.… His neuroexam remains unremarkable with normal deep tendon reflexes, Achilles, patellar, … Toes are downgoing.  No pathologic clonus.… Motor examination is normal proximally and distally in … lower extremities.  He has a smooth and fluid gait, nonspastic.”  The 2 July 2003 lumbar spine X-ray showed satisfactorily healing L4 and L5 compression fractures and very minimal compression.  The NARSUM recounted the history and interventions to date.  It documented “His current status is that he has constant low back pain, aggravated by bending, twisting, heavy lifting, and impact activities, and sometimes requiring opioid medication for treatment.”  The physical exam recorded “Examination of the lumbar spine revealed mild tenderness to pressure at the lumbosacral junction without palpable spasm or visible deformity.  Straight-leg raising [assesses sciatic nerve root compression by a herniated disc] sign was positive for complaints of pain down the posterior right thigh.  Waddell's signs [psychogenic, or nonorganic, manifestations of pain] were negative.”  The 2 December 2003 goniometer measured lumbar spine ROMs (pain limited) are in the chart.  There was normal strength and reflexes and no consistent sensory deficit was found.  The diagnosis was lumbar spine:  chronic low back pain status post vertebral fractures, unresponsive to conservative treatment, and necessitating significant limitation of physical activity.  The 13 January 2004 orthopedic surgery evaluation documented “He experiences severe back pain at a level of 6/10, pain radiating in both arms and down both legs, especially into his right posterior thigh.”  The physical exam recorded “Of the lower extremities, DTRs are 2+ and equal.  Motor strength is slightly diminished on the right extensor hallucis at 4+/5.  Sensory is diminished in the L5 dermatome on the right.  He has a positive straight leg raise on the right at 70 degrees, on the left at 80 degrees.  He has pain on the right sciatic notch to deep palpation and percussive pain over the L4-5.  He has 20 degree lateral side bending bilateral.  He has extension of 10 degrees.  He has forward flexion to approximately 4.7 cm from the floor.”  The impression listed status post multiple lumbar spine fractures, possible herniated nucleus pulposis, right lower extremity radiculopathy, and limitation of lumbar spine flexion.  The 21 January 2004 lumbar spine MRI showed old compression fractures at L4 (mild) and L5 (minimal).  The L5-S1 disk bulged posteriorly with mild right lateral stenosis, and slightly displaced the right S1 nerve root.  The 26 January 2004 orthopedic surgery follow-up documented “a prolonged episode of incapacity while he was on regular leave, causing him to seek military chiropractic help, who did chiropractic manipulation, and the patient was incapacitated at home on the couch for ten to fourteen days [the STR does not document physician directed bed rest].”  The examiner noted the CI had right-sided objective neurologic signs (diminished strength and sensation and a positive straight leg raise) and MRI findings.  He opined “I think proceeding with a series of three lumbar epidural steroids would be quite helpful to him for his pain.”  On 31 March 2004 pain management performed bilateral L3, L4, and L5 medial branch blocks (injection of local anesthetic on medial branch nerves to facet joints).  The procedure note documented “He reported his pain dropped from a 2 to a 0 post-procedure.  Before the procedure, he had no extension in the lumbar region.  Post-procedure, he had significant extension without pain or discomfort.”  The C&P exam documented “… low back pain was treated initially with a TLSO (thoracolumbar spinal orthosis) brace, … Presently no brace, only advised for the physical therapy exercises.  Pain is present daily.  It can easily flare up one to eight times a month.  He just has to sit down and relax and keep on doing weight shifting and exercises as advised. … Sciatica … sometimes more on the right and sometimes more on the left.  It comes and goes. … Treatment remains conservative.”  The physical exam recorded “Posture and gait reveals mild to moderate lumbar stiffness.  Both lower extremities no paresis, no foot drop or foot drag, no knee buckling noted during ambulation.  Heel strike, foot flat and takeoff are within normal limits.”  The thoracic spine revealed no abnormality but myofascial paraspinal strain (2/10 scale) was noted.  The lumbar spine exam revealed mild to moderate stiffness.  Initial pain was 3/10, but reached 5/10 scale when ROM was tested.  The pain did cause the episodic paraspinal spasms bilaterally, but there was no complaint of shooting pains down the legs.  Provocative tests and Waddel's signs were negative.  Lumbar spine ROMs, performed with repetitions (Deluca) are listed in the chart.  Lower extremity sensorimotor findings and reflexes were intact.  There was clinically no evidence of active sciatica, radiculitis, or peripheral neuropathy (injury or irritation of a peripheral nerve).

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

ThoracolumbarROM (Degrees)	
MEB ~6 Mo. Pre-Sep
	
PT ~5 Mo. Pre-Sep
	
 C&P ~ 1 Mo. Pre-Sep
	
Flexion (90 Normal)	70 (80,80,70)	90 (90,85,90)	70 dec to 65	
Combined (240)	190	185	205 dec to 180 	
Comment	Lumbar ROM Goniometer	Lumbar ROM	Lumbar ROM	
§4.71a Rating	10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The FPEB rated the lower back condition at 10%, coded 5235 (vertebral fracture or dislocation).  The PEB cited ROM, chronic pain following of L4-L5 fracture, and paraspinous muscle tenderness, without spasm or radiculopathy.  The VARD rated the lower back condition at 10%, coded 5237 (lumbosacral strain).  The VARD cited ROM, ROM limited by pain, stiffness, compression fracture, episodic paraspinal spasms, negative straight leg raising test, and no evidence of ataxia, radiculitis or neuropathy.  The ROM values in the proximate exams (MEB, PT and C&P) were consistent with the 10% rating.  Other routes to a rating higher than the PEB’s 10% were considered, but there was no evidence of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disc disease.  The Board agreed a 10% rating was supported based on range-of-motion criterion utilizing the General Rating Formula for Diseases and Injuries of the Spine.  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 lower back condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the headache and corneal scar conditions (aversion to sun and eye surgery) were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Contended Headache Condition.  The STR documents that the CI struck his head, and had a brief loss of consciousness, in the 16 October 2002 fall.  The 16 October 2002 head CT showed no evidence of acute hemorrhagic (bleeding), ischemic (inadequate blood supply) abnormality, or mass lesion.  The 18 October 2002 neurosurgery evaluation documented “Possible loss of consciousness … There is no history of hypertension, hypoxia, post-impact seizure.… The patient states that he has no headache.… He has had no visual problems, hearing problems.  He denies any numbness, tingling, paraesthesias, dysesthesias [abnormal sensations], ….”  The neurological evaluation was unremarkable with a Glasgow coma scale (scoring system for evaluating brain injury) of 15 (normal), normal motor strength, normal sensation, and normal deep tendon reflexes.  The clinical impression listed “a probable grade I concussion without apparent neurologic sequelae at this time.… No neurosurgical treatment necessary at this time….”  The 17 December 2002 neurosurgery evaluation documented “At this point, the patient seems to be bothered by headaches and difficulty sleeping … Given his continued headaches it might be reasonable to repeat the CT scan of his head without contrast to ensure that there is no evolution of a chronic subdural hematoma [blood between outer (dura) and middle (meninges) membranes enveloping brain], etc.”  The 14 March 2003 neurosurgery evaluation documented “The patient previously had a CT scan of the head because he was complaining of headaches.  That is unremarkable for a subdural.  The patient's neuroexam is unremarkable with good strength, normal reflexes, etc.  He still states he has headaches and some neck pain…. I have nothing further to offer from the neurosurgical standpoint and will be ceasing regular follow-up.”  The NARSUM documented “He was seen in consultation by Neurology on 15 January 2003 and diagnosed with post-concussive headaches.”  The diagnosis listed chronic headaches, with cervicogenic and post-concussive components, which does not cause him to fall below retention standards.  The 13 January 2004 orthopedic surgery evaluation documented “Because of his continuing difficulty with headaches he was seen by a neurologist at the Air Force Academy who diagnosed him with post- concussion headaches and gave him Nortriptyline and Imitrex.  Those [medications] have been stopped over the past eight months.  He continues to experience continuous left frontal headaches.”  The diagnoses listed post-traumatic headaches and post-concussive syndrome.  The C&P exam listed a history of “Headaches secondary to the cervicogenic and the posttraumatic post-concussive head trauma condition, but no seizures.  He denies any seeing, smelling, tasting or swallowing problems.”  The physical exam for cervical spine ROM noted  “repetitions with resistance did notice cervicogenic suboccipital headache….”  The diagnoses listed post-traumatic cervicogenic and post-concussive headaches.  The headache condition was not profiled or implicated in the commander’s statement.  It was not judged to fail retention standards by the MEB and was considered not unfitting by the PEB.  There was no indication from the record that this 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 headache condition; and, therefore, no additional disability ratings can be recommended.

Contended Corneal Scar Condition.  The STR documents that on 15 April 2003 the CI underwent photorefractive keratectomy (PRK).  Uncorrected preoperative visual acuity was right eye (oculus dexter [OD]):  20/70 and left eye (oculus sinister [OS]):  20/50 compared to a normal:  20/20.  Post-operatively, the CI developed a right eye central corneal infiltrate.  He was treated with antibiotic eyedrops.  Five weeks post-operatively, the infiltrate had resolved with a residual central scar.  The final ophthalmology encounter, 9 months after surgery, documented OD scar from previous infiltrate and haze.  The visual acuity listed OD:  20/30 and OS: 20/15.  The NARSUM documented “He had PRK surgery in April 2003 that was complicated by keratitis, and was left with a slight corneal scar.”  The diagnosis listed corneal scar with mild vision defect which did not cause him to fall below retention standards.  The eye C&P exam by optometry documented “Had PRK OU 2/2003 @ AFA by army doctors.  Developed an infection in the right eye following the surgery and was treated with antibiotic eye drops.  Following the infection, developed haze in right eye.”  Exam revealed the right eye had a small central epithelial scar and the left eye was clear.  The uncorrected acuity listed OD (distance):  20/25-2 (two letters on line read incorrectly) and OS (distance):  20/20.  The diagnoses listed status post PRK surgery, with OD central corneal scar from post-operative infection, glare from corneal scar, and mild photosensitivity.  The corneal scar condition was not profiled or implicated in the commander’s statement.  It was not judged to fail retention standards by the MEB and was considered not unfitting, and therefore not ratable, by the PEB.  There was no indication from the record that this 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 corneal scar condition; and, therefore, no additional disability ratings can be 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.  As discussed above, PEB reliance on AR 635-40 for rating the neck and back conditions was operant in this case and the conditions were adjudicated independently of that policy by this Board.  In the matter of the neck condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the lower back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended headache and corneal scar conditions, the Board unanimously recommends no change from the PEB determinations 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 20140519, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

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 XXXXXXXXXXXXXXXXXX, AR20150018357 (PD201402284)

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