RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03137
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080710

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, Food Service Specialist, medically separated for chronic neck pain, rated at 10%.

CI CONTENTION:  “Please consider all conditions”  

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 20080310	VA* - (~27 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Neck Pain and Limited Range of Motion (ROM) Secondary to Two Fusion Surgeries (September 2006 And March 2007).	5241	10%	Degenerative Spondylosis Cervical Spine, Status Post
Cervical Spinal Fusion with Scar	5241	20%	20100927	
Other x 0 	Other x 7	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20101007 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Neck Condition.  The service treatment record (STR) documents onset of neck pain without a specific history of trauma.  A cervical spine (C-spine) X-ray showed remote traumatic changes of the lower C-spine with an axial loading compression injury and degenerative disc disease (DDD) changes.  A C-spine X-ray showed disc space height loss at C4-C5 and C5-C6 with osteophytes (bony outgrowth reaction to repeated minor trauma/chronic inflammation), annular (disc fibrous exterior) calcifications, and straightening of the cervical lordosis (anterior spine curvature).  A C-spine MRI showed spondylosis (spine degenerative disease) at C4-C5 and C5-C6, mild central stenosis (narrowing) at C4-C5, disc bulge and herniation at C5-C6, and mild foraminal narrowing at C6.  At the neurosurgery evaluation the CI complained of 6 months of neck and arm (R > L) pain.  He reported 8/10 neck pain with radiation down the right arm along the tricep, forearm, and into the middle three fingers.  Because of severe degenerative changes at two levels, the neurosurgeon recommended a C5 corpectomy (surgical excision of a vertebral body) with a C4 through C6 fusion.  On the CI underwent a C5 corpectomy with a C4 through C6 iliac crest bone allograft (transplant of cadaver bone) and plate fusion.  A C-spine CT showed postsurgical changes, maintained spinal alignment, no evidence of hardware fracture, and right C4-5 and C5-6 neuroforaminal narrowing.  A C-spine X-ray showed intact plate and screws in good alignment.  There was progression of the translucency at both ends of the graft suggesting the corpectomy had not fused.  At the neurosurgery follow-up the CI reported his “buddy was fooling around” and hit him on the back of his neck.  This caused significant pain over the lower half of the back on his neck.  The neurosurgeon interpreted the imaging studies as a complete pseudarthrosis (false joint or nonunion with movement at an unhealed bone fracture) of the graft.  She recommended a re-do C5 corpectomy with C4-6 allograft and plate fusion.  On underwent a surgical removal of the fusion plate, pseudoarthrosis, and re-do of the C4 through C6 fusion.  Serial C-spine X-rays showed stable postsurgical changes, anterior fusion at C4-C5 and C5-C6, C3-4 degenerative changes, and degenerative disc disease (DDD).  At the neurosurgery evaluation the CI complained of constant 6/10 posterior neck pain and difficulty sleeping.  He denied arm symptoms, voice problems, or swallowing problems.  The neck exam revealed a well healed anterior incision and ROM was limited in all directions.  Hoffmann’s (reflects presence of upper motor neuron lesion from spinal cord compression) and Romberg's (assesses integrity of spinal dorsal columns and abnormal position sense [proprioception]) tests were negative.  Strength, sensation, and deep tendon reflexes (DTRs) were normal.  A C-spine X-ray showed status post anterior fusion of C4-C6 with possible right sided neural foraminal bony impingement.  The narrative summary (NARSUM) recounted the history and interventions.  The CI complained of constant 8/10 neck pain severe enough to prevent sleep, or wake him from sleep.  He denied radicular (irritation or injury of a nerve root) complaints.  Pain was exacerbated by prolonged sitting, prolonged standing, running, jumping, pushups, sit-ups, overhead lifting, and load bearing and relieved by rest and narcotic medications.  The cervical exam revealed a well healed anterior operative incision and bilateral paraspinous tenderness.  There was no palpable spasm, deformity, or muscular atrophy or hypertrophy.  The neck ROM was guarded and limited secondary to pain.  The Hoffman's and Spurling's (assesses cervical nerve root compression by a herniated disc) tests were negative.  Sensation and DTRs were normal.  The C-spine X-rays showed stable postsurgical changes, patent (open) neuroforamina, effusion (fluid collection) across the C4 through C6 intervertebral spaces, and spondylotic end plate changes from C4 through T1.  The examiner opined the CI had failed all conservative treatment and surgical protocols and had reached his maximum medical potential for improvement.  The diagnoses listed chronic neck pain and cervical spondylosis status post anterior cervical discectomy and C4-C6 fusion.  The C-spine active ROM values, measured (goniometer/inclinometer) by physical therapy (PT) for the MEB, are in the chart.  The C-spine exam revealed diffuse tenderness with muscle guarding during flexion and bilateral rotational measurements.  There was no abnormal gait due to muscle spasm or guarding and no abnormal spinal contour (scoliosis, reversed lordosis, or abnormal kyphosis).  

The Compensation and Pension (C&P) exam, 27 months after separation, recounted the history and interventions.  The CI complained of constant, moderate, anterior and posterior neck pain which extended down the back.  Pain interfered with sleep and was associated with stiffness, spasms, decreased motion, paresthesia (abnormal sensation, tingling, burning, prickling), and erectile dysfunction.  He denied fatigue, numbness, weakness, and bowel/bladder symptoms.  Symptoms were exacerbated by physical activity and stress and relieved by rest.  Pain prevented lifting over 10 pounds and prolonged standing, walking, and driving.  The CI could function without medication, was not receiving any treatment, and had not experienced any incapacitation in the past 12 months from his C-spine condition.  The physical exam revealed a normal posture and gait without assistive device for ambulation.  The C-spine exam showed normal spinal curvature and symmetry of spinal motion.  There was an anterior, linear scar without tenderness, skin breakdown, underlying tissue damage, inflammation, edema, or keloid (abnormal/excessive scar tissue).  There was diffuse C-spine tenderness with no evidence of radiating pain on movement, muscle spasm, guarding, loss of tone, or muscle atrophy.  There were no signs of cervical intervertebral disc syndrome with chronic and permanent nerve root involvement.  The repetitive active ROM values are in the chart.  The C-spine function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use.  Strength, sensation, and DTRs were normal.  There were no non-organic physical signs.  The C-spine X-ray showed postoperative changes and mild degenerative spondylosis at C3-C4 and C6-C7.  The diagnosis listed degenerative spondylosis of the C-spine status post cervical spinal fusion with scar. 

The Board directed attention to its rating recommendation based on the above evidence.  The informal PEB rated the neck condition at 10% (VA code 5241; spinal fusion).  The PEB cited neck pain, limited ROM secondary to two fusion surgeries, tenderness, no traumatic event noted, normal gait, no spasm, no deformity, and no radicular complaints.  The VA rating decision (VARD), citing the C&P exam 27 months after separation, rated the neck condition at 20% (5241).  The VARD cited degenerative spondylosis, status post cervical spinal fusion, X-ray findings, moderate neck pain, stiffness, spasms, paresthesia, scar, tenderness, pain exacerbated by physical activity and stress and relieved by rest, decreased ROM, ROM not additionally limited by repetitive use and no ankylosis, radiating pain, muscle spasm, guarding, loss of tone, or atrophy.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  The ROMs in the proximate (PT for MEB and C&P) exams were consistent with the 20% rating (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).  The higher 30% rating would require flexion of 15 degrees or less; or favorable ankylosis 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 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 disk disease.  The proximate (PT for MEB and C&P) 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 recommends a disability rating of 20% for the neck condition.

BOARD FINDINGS:  In the matter of the neck condition, the Board unanimously recommends a disability rating of 20%, coded 5241 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	
Neck Pain and Limited Range of Motion (ROM) Secondary to Two Fusion Surgeries	5241	20%	
COMBINED	20%	

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

SAMR-RB			

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite XXX, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXX, AR20160004044 (PD201403137)

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 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: 
(  ) DoD PDBR
(  ) DVA