RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03091
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070620

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O-3, Aviation, General, medically separated for “lumbar degenerative disc disease,” rated at 10%.  

CI CONTENTION:  His back condition continues to impact his daily activities.  His 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 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:  

IPEB - Dated 20070321	VA* - (~5 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar Degenerative Disc Disease	5299-5242	10%	Degenerative Disc Disease, Lumbar Spine	5243	20%	20071106	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 1 (equals SC, NSC & deferred)	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20080407 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Low Back Condition.  The service treatment record (STR) documents an early history of intermittent low back pain (LBP).  A lumbosacral spine X-ray showed vertebral body end plate deformities, with adjacent disc space narrowing, suspicious for Scheuermann’s (kyphosis) disease (anterior wedging of ≥5 degrees in at least three adjacent vertebral bodies).  A lumbar spine MRI showed degenerative disc changes and small protrusions of the disc content (nucleus pulposus) at the posterior lateral L4-L5 and L5-S1 spaces.  A lumbar spine X-ray showed questionable changes at L1-L2 and L5-S1 levels.  A lumbar spine X-ray showed endplate irregularities (T12-L1, L1-2, L2-3), mild spondylolisthesis (forward displacement of vertebra after a fracture) at L5-S1, and possible spondylolysis (deficient development or degeneration of a part [pars interarticularis] of vertebra) versus other facet disease.  An electrodiagnostic study was normal with no evidence of neuropathy (injury or irritation of a peripheral nerve) or radiculopathy (irritation or injury of a nerve root) involving the right leg.  A lumbar spine MRI showed extensive multilevel degenerative disc changes manifesting primarily as Schmorl's nodes (protrusions of disc cartilage through vertebral endplates) and a probable posterior annular tear at the L4-L5 disc.  At the orthopedic spine surgery consultation the CI reported his back started to ache following a period of protracted helicopter flying.  He complained of onset of significant sharp pain, which took about 2 weeks to resolve.  Since that initial presentation, he had “thrown his back out” about four times with symptoms lasting several weeks.  The 2-10/10 back pain was characterized as a left-sided dull ache with an associated “split second electrical shock” about two or three times a week.  Pain was exacerbated by sitting, driving, flying helicopters, and hyperextending his back and relieved by mild activities.  He complained of a feeling of bowel and bladder spasm but denied incontinence.  He denied fevers, chills, night sweats, and balance or hand function problems.  The physical exam revealed a normal tandem gait and station.  There was no evidence of misalignment, asymmetry, crepitation (grating sound or sensation), defects, masses, or effusions (fluid collection).  Cervical, thoracic, and lumbar spine range-of-motion (ROM) was documented as adequate.  Hoffmann’s (reflects presence of upper motor neuron lesion from spinal cord compression), Spurling’s (assesses cervical nerve root compression by a herniated disc), and Babinski (primitive reflex causing upturned toe) tests were negative.  Strength, sensation, deep tendon reflexes (DTRs), and pulses were normal.  The thoracic spine X-ray showed mild spondylosis (spine degenerative disease) and the lumbar spine X-ray showed degenerative changes at the L4-L5, greater than L2-L3 and L1-L2, levels.  The diagnosis listed mechanical back pain.  The surgeon opined that the CI did not require any type of surgical intervention and did not recommend any further injections.  He recommended aggressive formal physical therapy (PT) and avoidance of activities which made it worse.  The narrative summary (NARSUM) by orthopedic surgery recounted the history, diagnostic studies, and interventions.  Following a period of increased tempo of flight operations, the CI reported he bent over, and his back “went out.”  He was treated with bed rest and medication and his symptoms resolved after two weeks.  Since that initial episode, he had five to six recurrences where he felt “a pop in his back,” and had significant pain.  These recurrences lasted up to 4 weeks.  The CI complained of constant, marked, LBP and pain at night when supine.  Pain was sometimes associated with numbness and tingling in his legs.  There was a single instance where the LBP shot down the back of his left leg into his foot.  The pain when supine, resolved a number of minutes after arising.  He was taking an antidepressant (amitriptyline) off-label for chronic pain management.  He had stopped taking a muscle relaxant (Flexeril) because it made him sleepy and the nonsteroidal anti-inflammatory drug (NSAID) (Mobic) was ineffective.  The physical exam recorded that the CI could toe and heel walk.  The spine exam revealed mild lumbar spinal tenderness, but no spasm was detected.  Pain limited active ROM was measured with a goniometer.  Documented ROM was flexion of 30 (90 normal), extension of 11 (30), bilateral lateral bending of 10 (30), right rotation of 21 (30), and left rotation of 20 (30) degrees.  The CI was markedly uncomfortable in the supine position and straight leg raise ([SLR] to assess sciatic nerve root compression by a herniated disc) tests could not be performed supine.  Seated SLRs were negative.  The DTRs were normal and there was no weakness or sensory abnormality.  Pain was rated as constant and moderate.  The diagnosis listed degenerative disc disease (DDD) of the lumbar sacral spine.  Pain management performed a number of minimally invasive procedures to the lumbar spine to reduce inflammation and pain.  These included epidural steroid injections (steroid and anesthetic injection into epidural space), medial branch nerve blocks (steroid and anesthetic injection into medial branch nerves that supply facet joints), and trigger point injections (anesthetic and NSAID injection into tender areas which refer pain to another part of the body [trigger points]).  

The VA Compensation and Pension (C&P) exam recounted the history, diagnostic studies, and interventions.  The CI complained of chronic 3-4/10 LBP with exacerbations to 10/10.  Pain occasionally radiated into the left buttock and left lateral thigh.  Pain was characterized as throbbing and aching with an occasional "electric jolt."  He was taking an analgesic/opioid combination (Percocet), a muscle relaxant (Skelaxin), and an NSAID (ibuprofen).  Pain was exacerbated by unpredictable precipitating factors and relieved by lying down and medication.  He denied a history of trauma, weakness, incontinence, erectile dysfunction, or incapacitation in the past 12 months.  The CI walked unaided without a mechanical aid, brace, or orthosis.  The CI was able to do his daily activities as a graduate student, had not had any significant time loss, and could walk long distances on flat terrain.  The physical exam revealed a normal posture, stance, and gait.  The spine exam revealed palpable muscle spasm in the lower lumbar area with some straightening of the lumbar curve.  There was no scoliosis or other contour abnormalities.  The active ROM measured with a goniometer was flexion of 60, extension of 0, bilateral lateral bending of 20, and bilateral rotation of 25 degrees.  The CI reported LBP increased at the end of active ROM, and further increased with five repetitions.  The ROM was limited by pain and spasm.  The SLRs were negative.  Motor, sensory, and DTRs were normal.  The lumbar spine MRI showed multilevel DDD, disc desiccation, and a minimal posterior disc bulge at L4-L5.  The lumbosacral spine X-ray was normal.  The diagnosis listed moderately severe chronic LBP secondary to DDD of the lumbar spine.

The Board directed attention to its rating recommendation based on the above evidence.  The informal PEB rated the low back condition at 10% (VA code 5299-5242; rating by analogy-degenerative arthritis of the spine).  The PEB cited lumbar DDD, no neurologic deficit, normal electrodiagnostic study, ROM limited by pain, and localized tenderness.  The VA rating decision (VARD), citing the C&P exam five months after separation, rated the low back condition at 20% (5243; intervertebral disc syndrome).  The VARD cited constant, throbbing, aching, 3-4/10 pain, up to 10/10 pain, occasional "electric jolt" radiation to left buttock and left lateral thigh, no neurologic abnormalities, no use of a brace, walking unaided, normal posture and gait, lumbar muscle spasm, ROM, ROM not additionally limited by repetitions, medication use, and lumbar spine degenerative changes by MRI.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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.  The MEB exam documented the CI could toe-and-heel walk and there was no spinal muscle spasm.  The C&P exam documented a normal gait and lower lumbar muscle spasm.  While there was some straightening of the lumbar curve, there was no scoliosis or other contour abnormalities.  The ROM in the MEB exam was consistent with the 40% rating (flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine).  The higher 50% rating would require unfavorable ankylosis of the entire thoracolumbar spine.  The ROM in the C&P exam was consistent with the 20% rating (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 Board assigned less probative value to the MEB exam because it occurred before the majority of procedures performed by pain management.  The Board assigned more probative value to the C&P exam because it was more comprehensive in that it measured active ROM after repetition.  The C&P exam, being temporally remote from the increased activity and rigors attendant to military life, more accurately reflected the CI’s condition after separation.  Other routes to a rating higher than the PEB’s 10% were considered, but there was no evidence of additional functional loss from repetitive use to warrant application of VASRD §4.45; and no evidence of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disc disease.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the low back 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.  As discussed above, PEB reliance on the USAPDA pain policy AR 635-40 DoDI 1332.39 for rating the low back condition was operant in this case and the condition was adjudicated independently of that policy/ instruction by this Board.  In the matter of the low back condition, the Board unanimously recommends a disability rating of 20%, 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	RATING	
Lumbar Degenerative Disc Disease	5242	20%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140619 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 XXXXXXXXXXXXXXXXXXXX, AR20160005019 (PD201403091)

1. I have reviewed the enclosed Department of Defense Physical Disability Board of
Review (000 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 20%
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:
( ) 000 PDBR
( ) OVA