RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02336
BRANCH OF SERVICE:  Army  	                        SEPARATION DATE:  20071019

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3, Field Artillery Mechanic, medically separated for ‘lumbago,” with a disability rating of 0%.   

CI CONTENTION:  “Please consider all conditions.”  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 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 – 20070924	VARD - 20071128  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar Degenerative Disk Disease	5299-5242	0%	Intervertebral Disc Syndrome with Degenerative Arthritis Changes Thoracolumbar Spine (Claimed as Disc Protrusion, Thoracolumbar Spine)	5243	10%	20071006	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Low Back Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his low back approximately 1 year prior to referral for MEB.  The CI initially injured his back diving for a soccer ball, and 2 weeks later he reinjured it lifting an engine.  Lumbosacral spine diagnostic imaging (X-ray) showed spina bifida occulta (developmental defective closure of bony spinal cord encasement) of L5 and accentuation of the lumbar lordosis (anterior spine curvature).  A 23 October 2006 lumbar spine diagnostic imaging (MRI) study showed transitional vertebra (congenital variation of lumbosacral joint involving lowermost lumbar vertebra or uppermost sacral segment) with partial lumbarization (congenital anomaly where the uppermost sacral segment [S1] is not fused creating a 6th lumbar segment [L6]) of S1, mild disc protrusion (L2-L3, L3-L4, L4-L5, and L5-S1), early spondylosis (spine degenerative disease) at L3-L4, and no significant stenosis (narrowing) at any level.  A 4 December 2006 electro-diagnostic (EDX) study was normal with no evidence of radiculopathy (nerve root irritation or injury) or peripheral nerve pathology.  At a family practice encounter the CI complained of 5.5 months of low back pain with radiation to the left lower extremity (LE).  The physical examination documented a normal gait.  The lumbar/lumbosacral spine examination revealed a normal appearance and motion.  There was tenderness with no muscle spasm.  Pain limited range of motion (ROM) was flexion of 45 (90 normal) and extension of 30 (30) degrees.  Straight leg raise (SLR) tests (assess for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) were negative.  Strength, sensation, and deep tendon reflexes (DTRs) were normal.  At a physical therapy (PT) encounter, the CI complained of throbbing, stabbing, and burning pain and numbness, and tingling primarily to the left low back, posterior buttock, and thigh to the knee.  The physical examination documented an antalgic (assuming a gait or posture to lessen pain) gait which slowly resolved.  The lumbar spine examination revealed central (L1-L5) and left tenderness and a mild increase in paraspinal muscle tone (L>R).  The ROM was flexion of 50% ~ 45 (90), extension of 25% ~ 8 (30), and bilateral side bending of 50% ~ 15 (30) degrees.  The SLR tests were negative and strength and sensation were normal.  A 12 March 2007 lumbar spine MRI showed minimal degenerative change with no neuroforamen (nerve root opening) or central canal stenosis.  A 15 March 2007 lumbar spine diagnostic imaging (CT) study was interpreted as normal with symmetrical disc bulging (L3-4, L4-5, and L5-S1).  A repeat lumbar spine MRI on 16 March 2007 showed mild broad-based disc bulges (L3-4 and L4-5) without spinal canal stenosis, neuroforamina stenosis, or nerve root encroachment.  Pain management performed serial L3-L4 lumbar epidural steroid injections with local anesthetic and corticosteroid.  A repeat 15 June 2007 EDX study was normal.  Pain management performed serial bilateral (L4, L5, and S1) lumbar facet injections with local anesthetic and corticosteroid.  Repetitive ROM was measured by PT with a goniometer/inclinometer for the MEB.  Active thoracolumbar spine ROM values were flexion of 30/25/25 (90 normal), extension of 10/10/15 (30), right lateral flexion of 10/15/15 (30), left lateral flexion of 15/15/15 (30), bilateral rotation of 20/20/20 (30), and total of 110 (240) degrees.  In the 28 August 2007 NARSUM, 2 months before separation, the CI complained of low back pain and intermittent pain radiating down his left leg with numbness of the left foot.  The CI failed non-surgical management which included activity modification, PT, traction, pain management, and medications.  Neurosurgery recommended no surgical intervention.  The physical examination documented a normal gait.  The back examination revealed a normal spinal contour with no muscle atrophy or paraspinal muscle spasm.  There were no radicular signs noted on examination and sensation and pulses were normal.  The examiner referred to the PT ROM measurements for the MEB and transcribed the written comments verbatim.  The examiner recounted the findings of MRIs and EDXs.  The diagnosis listed lumbago.  At the pain management follow-up, the CI denied any adverse reaction or complication from his 27 August 2007 bilateral lumbar facet injections and reported his back pain was decreased approximately 40-50%.  The physical examination revealed some pain on deep palpation of his bilateral lumbar facet joints (L4, L5, and S1).  The impression listed lumbar facet syndrome.  The CI indicated that he wanted to discuss further treatment options, but he “did not want to have surgery done.”  The examiner discussed a medial branch block (injection of local anesthetic on the medial branch nerves that supply the spine facet joints), to determine the feasibility of a rhizotomy (nerve root sectioning), and planned to proceed with the procedure.  At the 6 October 2007 compensation and pension (C&P) exam, 2 weeks before separation, the CI complained of 1 year of constant middle back pain with associated stiffness, weakness, and radiation to the bilateral hips and legs.  Pain was characterized as squeezing, burning, aching, and sharp and rated as 10/10.  Pain was exacerbated by stress, physical activity, walking, prolonged standing, and prolonged sitting and was relieved by rest and the medication.  At the time of pain, the CI could function with medication.  He reported 3 incidents over the past year, for a total of 3 days of incapacitation.  The physical examination documented a normal gait.  The thoracolumbar spine examination revealed left lumbar muscle tenderness.  There was normal curvature, symmetry, and symmetry of motion with no muscle spasm or ankylosis (joint stiffening or immobility).  The SLR was positive on the left and negative on the right.  Thoracolumbar spine active ROM values were flexion of 80 (90), extension of 10 (30), right lateral flexion of 30 (30), left lateral flexion of 10 (30), right rotation of 30 (30), left rotation of 30 (30), and total of 170 (240) degrees.  Repetitive ROM was additionally limited by 0 degrees by pain, fatigue, weakness, and lack of endurance and was not additionally limited by incoordination.  There was evidence of left leg radiating pain on movement and signs of intervertebral disc syndrome with left 4/5 strength of hip adduction and knee extension.  Gross examination of the muscles was within normal limits and DTRs were normal.  A thoracic spine X-ray showed minimal diffuse spondylosis.  The diagnosis listed intervertebral disc syndrome with degenerative arthritis and likely involved sciatic nerve.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5242 code (degenerative arthritis of the spine) citing degenerative disc disease, back pain, ROM limited by pain, no tenderness, no spasm, no abnormal contour, and no evidence of motor neurologic deficit.  The VA assigned a 10% rating under the 5243 code (intervertebral disc syndrome) based on the VA C&P examination 2 weeks before separation, citing intervertebral disc syndrome, degenerative arthritis, spondylosis, ROM, repetitive ROM limited by pain, fatigue, weakness, and lack of endurance changes, no tenderness, no spasm, no ankylosis, no evidence of radiating pain on movement, and no evidence of motor neurologic deficit.  The ROM values in the C&P examination were consistent with the 10% rating (flexion of greater than 60 degrees but not greater than 85 degrees; or a combined ROM of greater than 120 degrees but not greater than 235 degrees of the thoracolumbar spine).  The higher 20% rating would require (flexion of greater than 30 degrees but not greater than 60 degrees; or a combined ROM of not greater than 120 degrees of the thoracolumbar spine).  The ROM values in the PT for MEB examination were consistent with the 40% rating.  Recognizing the temporal relationship to the date of separation, the board considered the relative probative value of the proximate examinations.  The Board assigned less probative value to the PT for MEB examination because ROM was measured on the day of an invasive procedure by pain management.  Three days later at the pain management follow-up, the CI reported his back pain was decreased approximately 40-50%.  The Board assigned more probative value to the C&P examination, as reasonably reflecting the severity of the disability at the time of separation, because it occurred after an appropriate period of recovery following multiple therapeutic interventions (epidural steroid injections and facet injections) by pain management.  While the CI complained of pain radiating into the left/bilateral leg (s), serial EDXs were normal.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  The critical decision is whether or not there was significant motor weakness which would impact military occupation specific activities.  There was no evidence that motor weakness or sensory loss existed to any degree that could be described as functionally impairing.  The Board therefore concluded that additional disability rating was not justified on this basis.  While the CI reported incapacitating episodes, there was no documentation of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disc disease.  While the proximate examinations documented tenderness, there was no evidence of muscle spasm, abnormal spinal contour, or abnormal gait.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  Other routes to a rating higher than the PEB’s 0% were considered, but there was no evidence of additional functional loss from repetitive use to warrant application of VASRD §4.45.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the low back condition, coded 5242.  

BOARD FINDINGS.    In the matter of the low back condition, the Board unanimously recommends a disability rating of 10%, coded 5242 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Lumbar Degenerative Disk Disease  	5242	10%	
COMBINED	10%	

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

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 AR20160011085  (PD201402336)

1.	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, accept the Board's recommendation to modify the individual's disability rating to 10% without re-characterization of the individual's separation.  This decision is final.

2.	I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.

3.	I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY: 

CF:
( ) DoD PDBR
( ) OVA