RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03232
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050504

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Automated Logistical Specialist) medically separated for “chronic subjective back pain, s/p L5-S1 fusion” rated 10%.  

CI CONTENTION:  The CI requested that the Board review all of his conditions.  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 20050304	VA* - (~3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Subjective Back Pain , S/P L5-S1 Fusion	5241	10%	Residuals, Fusion L5-S1 for Degenerative Disc Disease	5243	20%	20050815	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 1	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20050913 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Subjective Back Pain, S/P L5-S1 Fusion Condition. The CI was first seen for low back pain (LBP) on 3 March 20001 and thought to have strained his back.  He was treated with medications and duty restrictions with improvement, but continued pain.  Magnetic resonance imaging in June 2001 showed degenerative disc disease at L5-S1 as well as pathologic changes of the spine (Modic changes) which are highly correlated with LBP.  He was seen periodically over the next few years for continued pain.  A discogram, a procedure to isolate the symptomatic disc, was positive at L4-5.  He subsequently underwent fusion at L4-5 on 15 April 2004.  In physical therapy (PT) on 27 August 2004, 6 months after surgery, he had full flexion and moderately reduced extension.  Following surgery, the previously recorded radicular symptoms resolved.  He was seen again on 21 September 2004 and noted to have a guarded gait and marked limitation in extension and flexion.  Three weeks later he reported significant improvement in PT, but in Orthopedics on 22 October 2004, he noted increased pain after lifting at work.  The CI then requested initiation of an MEB at the 13 Jan 2005 orthopedics appointment.  The narrative summary (NARSUM) was dictated that same day, 4 months prior to separation and 9 months after surgery, by the treating spine surgeon.  He noted that the CI reported improvement in the LBP after surgery, but recurrence of symptoms after the weather had gotten colder.  No radicular symptoms were recorded.  On examination, the scar was well healed, spasm absent, gait normal, neurological examination normal, and provocative testing for nerve root irritation negative.  X-rays showed a good repair.  The CI had range-of-motion (ROM) measurements in PT that same day and showed a marked limitation in all planes secondary to pain.  These values are not consistent with the essentially normal examination recorded by orthopedist that day.  At the MEB examination, the CI reported that he could (not) bend, squat, or sit long.  The MEB physical examiner noted limitation of ROM without quantification.  Reflexes and sensation were normal, but the motor testing and gait were both limited due to pain.  Provocative testing for nerve root irritation was negative.  Spasm was not recorded, but lumbo-sacral tenderness was present.  At the VA Compensation and Pension (C&P) examination performed 3 months after separation and 16 months after surgery, the CI reported ongoing LBP and that his girlfriend often had to help him dress.  She was present and confirmed this statement.  His LBP radiated to the left buttock.  He used a cane with flares.  He had not worked since separation.  Incapacitation was not recorded.  On examination, the gait was non-antalgic (normal).  He was able to tie his shoes without difficulty even though he reported increased pain with bending over.  No ambulatory aid was in use.  Provocative nerve root testing was negative.  The neurological examination was normal.  X-rays showed expected post-operative changes (consistent with a good repair).  The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)	PT/MEB ~4 Mo. Pre-Sep	VA C&P ~3Mo. Post-Sep	
Flexion (90 Normal)	15 (15/16/14)	60	
Combined (240)	110	150	
Comment	Nml gait	*Values after repetition.  Pain with motion	
§4.71a Rating	40%	20%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the back at 10% for subjective LBP with the ROM limited by pain, coded 5241 (spinal fusion).  The VA rated the back at 20%, coded 5243 (intervertebral disc syndrome).  The Board considered the evidence.  It noted that the ROM values obtained by PT support a 40% rating.  However, these are not consistent with the orthopedic evaluation done that same day.  The VA C&P examination is one month closer to separation.  It is more internally consistent although a disparity in movement between measured and when not aware of observation was present.  It is also more remote from surgery and therefore more reflective of the permanent disability.  The VA examination is therefore assigned a higher probative value for rating.  It supports a 20% rating for flexion limited to 60 degrees.  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 back condition retaining the 5241 code.  The Board did not find evidence to support the presence of an unfitting radiculopathy at separation.  

BOARD FINDINGS:  In the matter of the chronic back pain 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	
Chronic Subjective Back Pain, S/P L5-S1 Fusion 	5241	20%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140522, 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
(AH RC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

JUL 19 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX, AR20160004408 (PD201403232)

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