RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03118
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090125

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Cavalry Scout, medically separated for “spinal fusion with cervical spine pain” with a disability rating of 10%.

CI CONTENTION:  The CI made no specific contention.  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 – 20081027	VARD - 20090320	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Spinal Fusion of the Cervical Spine at C5-C6…	5241	10%	S/P…C5-6…Fusion…	5241	10%	20081229	
			Residual Surgical Scar, C-Spine	7804	0%	20090105	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Spinal Fusion with Cervical Spine Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent cervical spine surgery with fusion of C5-C6 in January 2007.  Following surgery, further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “cervical spondylosis” and “intervertebral disc degeneration-cervical” for PEB adjudication.

At the MEB NARSUM examination in October 2008, 3 months before separation, the CI reported neck pain in combination with other medical conditions limited running to 1/2 mile.  Pain was tolerable with medications unless exacerbated by activity, remaining in one position for extended periods, bending over, or lifting objects.  The examination revealed mid-neck tenderness without spasm or guarding.  The range of motion (ROM) was decreased in rotation and lateral flexing.  The neurologic examination was normal.

At the VA Compensation and Pension (C&P) examination in December 2008, 1 month before separation, the CI reported chronic neck pain with flare-ups two times per week.  Pain flare-ups were precipitated by increased activity (or minimal provocation), might last up to 1 day, and were relieved by rest and medication.  The CI denied radiation of pain in the upper extremities, but did indicate he experienced rare episodes of numbness and tingling.  He denied prescribed bed rest in the previous year due to the neck condition.  The examination revealed decreased ROM of flexion 40 degrees (normal 45) with combined ROM at 165 (normal 340).

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA rated the neck condition 10% under code 5241 (spinal fusion), citing limitation of motion.  The VA additionally rated the cervical surgical scar at 0% under code 7804 (scar, unstable or painful).  Board members noted the NARSUM examination ROM supports a 10% rating for tenderness while the VA C&P examination ROM supports a 20% rating for limited combined ROM.  Board members extensively deliberated the totality of the record and determined the overall disability picture at the date of separation supports no greater than a 10% rating.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula, or evidence of ratable peripheral nerve impairment which would provide for additional rating.  After due deliberation, and in consideration of all 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 cervical spine condition.

BOARD FINDINGS:  In the matter of the cervical spine 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 20140624, 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 XXXXXXXXXXXXXXXXXXXXX AR20160011111 (PD201403118)

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