4:47 RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02977
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090127

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Health Care Specialist) medically separated for “intervertebral disc syndrome…with no neurologic deficits,” rated 10%. 

CI CONTENTION:  The CI contends that she was not evaluated for her traumatic brain injury (TBI) condition.  Her 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 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 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 20081125	VA* - (~4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Intervertebral Disc Syndrome	5243	10%	Intervertebral Disk Syndrome	5243	20%	20090514	
Other MEB/PEB Conditions x 2 (Not In Scope)	Other x 13 	
RATING:  10%	COMBINED RATING:  80%	
*Derived from VA Rating Decision (VARD) dated 20090701 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Neck Condition.  The service treatment record (STR) documents that the CI sustained a neck injury during combative training.  The following day she hyperextended her neck while gargling and felt immediate pain and stiffness.  Serial cervical spine X-rays showed reversal of the normal cervical lordosis (anterior spine curvature) at C5-C6, but with no bony or soft tissue abnormalities.  A C-spine MRI showed cervical kyphosis (posterior spine curvature) centered at the C5-C6 intervertebral disc level with hypertrophy of the posterior longitudinal ligament.  The radiologist opined that these findings might be secondary to muscle spasm.  Serial C-spine X-rays showed reversal of the normal cervical lordosis at the C5-C6 disc level.  A C-spine MRI showed reversal of the normal cervical lordosis at C5-C6, a moderate posterior disc bulge at C5-C6, multilevel disc desiccation and no soft tissue abnormalities.  A C-spine CT showed reversal of the normal lordotic curve at C5 and no fractures, subluxations, or soft tissue abnormalities.  The neurosurgery consultation reported the CI complained of 6 weeks of persistent cervicalgia (neck pain) radiating to the base of her neck.  The pain was unresponsive to medications, heat, ice, and chiropractic interventions and the CI was evacuated from the theater.  The physical exam documented the CI did not appear uncomfortable and was moving her head and neck and in an animated fluid fashion while describing the history.  The neck exam revealed no abnormalities there was no decrease in suppleness.  The midline paraspinal musculature was tender and there was pain elicited by motion.  Hoffman's sign (reflects presence of upper motor neuron lesion from spinal cord compression) was not demonstrated.  Muscle bulk, tone, and strength were normal.  Deep tendon reflexes (DTRs) and sensation was normal and no peripheral neuropathy (injury or irritation of a peripheral nerve) was noted.  The diagnoses listed C5-C6 bulging disc and cervicalgia.  The neurosurgeon recommended a trial of a cervical collar with gentle constant axial traction and a muscle relaxant.  The repeat C-spine MRI showed reversal of the cervical lordosis with kyphosis at the C5-C6 level and a small right paracentral C5-C6 disc bulge (unchanged compared to prior exam).  The C-spine range-of-motion (ROM) values, measured by physical therapy (PT) with a goniometer, are in the chart.  The repetitive, active ROM was limited due to pain.  The physical exam documented a normal gait.  The spine exam revealed increased thoracic kyphosis, but no other abnormal spinal contour.  There was no localized tenderness, muscle spasm, or guarding.  An electrodiagnostic study showed no evidence of a right upper extremity cervical radiculopathy (irritation or injury of a nerve root).  The narrative summary (NARSUM), recounted the history and interventions.  The CI complained of constant 4/10 pain at baseline with exacerbations to 9/10.  She was prescribed Mobic, a nonsteroidal anti-inflammatory drug (NSAID) and a muscle relaxant (Robaxin).  Pain was exacerbated by repetitive motion and impact activities and the CI denied significant palliative factors.  The CI did not experience significant improvement from activity modification, PT, physical medicine, acupuncture or medications.  Because there was no guarantee of improvement with surgical intervention, the CI elected to start the medical board process.  The physical exam documented a normal gait.  The focused neck exam revealed an abnormal spinal contour with reversed lordosis, or abnormal kyphosis, of the C-spine.  There was no muscle atrophy, deformity or scarring.  There was tenderness of the cervical spinous processes and paracervical musculature.  Pain was elicited with axial loading and all directions of motion.  The Spurling test (assesses cervical nerve root compression by a herniated disc) was negative.  Strength and DTRs were normal but sensation was decreased in the dorsal aspects of the hands (L > R).  The C-spine ROM values measured with a goniometer are in the chart below.  The diagnosis listed chronic neck pain secondary to cervical disc disease.  The VA Compensation and Pension (C&P) exam recounted the history and interventions.  The CI complained of right neck pain with radiation between the scapulae.  It was characterized as a constant, daily, aching, 2-9/10 pain.  She reported associated fatigue, stiffness, and decreased motion but denied weakness, spasms, and incontinence.  The CI did not report any specific precipitating factors and denied flare-ups and incapacitating episodes.  She additionally reported that her thumb, index, and middle fingers go numb several times per week.  Medications were an NSAID (Mobic) during the day and a muscle relaxant (Robaxin) at night.  The physical exam documented a normal posture and gait without aids for ambulation.  The C-spine exam revealed an abnormal curvature with reverse lordosis/kyphosis with tenderness.  There was no muscle atrophy, weakness, spasm, or guarding.  There was no muscle spasm, localized tenderness, or guarding severe enough to be responsible for an abnormal gait or abnormal spinal contour.  The C-spine ROM values are in the chart.  There was objective evidence of pain, but no additional limitations after three repetitions of ROM.  Muscle tone, strength and DTRs were normal and there were no pathologic reflexes.  There was decreased light touch sensation of the bilateral thumb, index and middle fingers and upper arms.  Position, vibration, and pinprick sensation were intact.  The diagnosis listed reversal of normal cervical lordosis, of uncertain etiology. 

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation are summarized in the chart below.

Cervical ROM
(Degrees)	PT ~8 Mos. Pre-Sep	MEB ~3 Mos. Pre-Sep	VA C&P ~4 Mos. Post-Sep	
Flex (45 Normal)	35 (35, 34, 35)	35 (35, 35, 34)	40	
Extension (45)	30 (35, 35, 32)	30 (30, 28, 29)	25	
R Lat Flexion (45)	25 (26, 25, 26)	30 (32, 32, 32)	35	
L Lat Flexion (45)	30 (30, 30, 31)	35 (37, 35, 36)	30	
R Rotation (80)	35 (38, 38, 36)	45 (43, 42, 43)	60	
L Rotation (80)	40 (40, 40, 41)	35 (38, 37, 37)	80	
Combined (340)	195	210	270	
§4.71a Rating	10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The Informal PEB rated the neck condition at 10%, coded 5243 (intervertebral disc syndrome).  The PEB cited a moderate disc bulge at C5-C6 by imaging, tenderness, no spasm, no guarding, kyphosis from bony change and not due to spasm or guarding, no neurologic deficits relative to her C-spine, ROM, rated for tenderness and limited ROM.  The VA rating decision (VARD), citing the C&P exam 4 months after separation, rated the neck condition at 20%, coded 5243.  The VARD cited X-ray findings, tenderness, stiffness, no spasm, no guarding, no atrophy, no radiculopathy, abnormal spinal curvature, reversal of normal cervical lordosis, kyphosis, spondylosis, ROM, and painful ROM.  The ROMs in the exams supported a 10% rating (flexion of greater than 30 degrees but not greater than 40 degrees; or a combined ROM of greater than 170 degrees but not greater than 335 degrees).  The higher 20% rating would require (flexion of greater than 15 degrees but not greater than 30 degrees; or a combined ROM of not greater than 170 degrees of the C-spine).  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 an additional disability rating was not justified on this basis.  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 disc disease.  The proximate exams documented a normal gait with no evidence of cervical spinal muscle spasm.  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 neck condition.

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 neck 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 20140528, 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 XXXXXXXXXXXXXXXXXXXX, AR20160005470  (PD201402977)

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