RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03164
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040716

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Petroleum Supply Specialist) medically separated for “chronic back pain, status post L5-S1 fusion, without neurologic abnormality” rated at 10%. 

CI CONTENTION:  “Please consider all conditions, Lumbar Fusion PTSD, Hypertension, Depression.”

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 20040430	VA* - (~4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain, Status Post L5-S1 Fusion, without Neurologic Abnormality	5241	10%	Degenerative Disc Disease, Residuals of L5-Sl Fusion	5242-5243	20%	20041103	
Other x 0 	Other x 4	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20041123 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Back Pain, Status Post L5-S1 Fusion, without Neurologic Abnormality.  Treatment records evidence that the CI reported the onset of back pain after a motor vehicle accident in Korea in 1994.  He presented with acute lower back pain in 2002.  Radiographic evaluation dated 26 April 2002 demonstrated mild disc space narrowing with evidence of degenerative changes at lumbosacral junction.  The CI was treated conservatively without resolution of the lower back pain with radiculopathy.  In December 2002 the CI underwent a lumbar interbody fusion.  The narrative summary (NARSUM) physical examination, approximately 1-1/2 years prior to separation (2 months after spinal fusion) demonstrated pain limited thoracolumbar range of motion, negative radiculopathy testing, and the absence of paraspinal muscle spasms.  The examiner noted X-ray results which demonstrated “a solid fusion at L5-S1 with hardware in place.”  At the VA Compensation and Pension (C&P) examination performed four months after separation, the CI reported 6/10 sharp low back pain with tingling in the right lower extremity to the calf.  The pain prevented standing for greater the 15 minutes, walking greater than 1-2 miles, and running.  The physical findings were a well healed scar, painful thoracolumbar flexion to 80 degrees, extension to 25 degrees, and additional limitation of lateral flexion due to pain.  There was no evidence of paraspinal lumbar guarding or muscle spasms or radiculopathy.  A diagnosis of degenerative disc disease, residuals of L5-S1 fusion was rendered.   

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the lower back pain condition 10%; coded 5241 (spinal fusion).  VA rated the condition at 20%; coded 5242-5243 (degenerative arthritis of the spine- Intervertebral disc syndrome).  The Board considered whether the evidence supported a higher than 10% rating.  There was no evidence of thoracolumbar forward flexion limited to 30 to 60 degrees, a combined range of motion less than 120 degrees, muscle spasms/guarding with abnormal spinal contour for a higher rating, or incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months prior to separation for a higher rating.  The Board determined that there was no evidence of an unfitting radiculopathy for an additional disability rating.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 10% for the lower back pain condition was appropriately recommended in this case.

BOARD FINDINGS:  In the matter of the lower back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20140625, 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 XXXXXXXXXXXXXXXXXXXX, AR20160004394 (PD201403164)

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: