RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03413
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090627

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, M1 Armor Crewman, medically separated for “spinal fusion L4-5 and L5-S1,” with a disability rating of 20%.  

CI CONTENTION:  The applicant stated “Spinal Fusion/PTSD.”  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 - 20090316	VARD – 20091001	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Spinal Fusion L4-5 & L5-S1	5241	20%	DDD, Lumbar Spine, S/P Fusion L4-5 & L5-S1	5010-5242	10%	20090624	
			Dyssomnia associated w/ DDD Lumbar Spine at L4-5 & L5-S1	9499-9435	NSC	20090624	
RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Spinal Fusion L4·5 and L5·S1.  According to service treatment records and the narrative summary (NARSUM), the CI’s lower back condition began in January 2007 after an IED [improvised explosive device] blast and was aggravated after bending over to pick up a motorcycle helmet in 2008.  Radiographic studies showed L5-S1 disc herniation and L4-5 disc degeneration with a mild bulge.  The CI underwent back surgery, with a lumbar anterior L4-5, L5-S1 fusion, in July 2008.  He continued having back pain with pain radiating into his leg.  During the physical therapy clinic appointment on 17 November 2008 (7 months prior to separation), the CI reported back pain as 3/10 aggravated by lifting; prolong sitting or standing and jarring.  He denied numbness or tingling.  On examination the CI’s gait was mildly antalgic due to reduced trunk mobility.  Sensation was intact to light touch with normal muscle strength.  The exam is summarized below.  Despite treatment, the CI’s back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for a Medical Evaluation Board (MEB).  

The MEB NARSUM exam on 26 January 2009 (5 months prior to separation) noted complaints of back pain 3/10 when taking medication which was worse with prolonged standing, prolonged sitting or hard breathing.  The physical exam showed normal strength in the major muscle groups and no sensory deficits in the lower extremities.  The contour of the spine was normal and the CI ambulated normally without any aids.  There was tenderness to the paraspinal muscles in the lower lumbar spine without palpable spasm.  The ROM exam is summarized below.  

At the VA Compensation and Pension (C&P) examination on 17 June 2009, performed 3 days before separation, the CI reported constant back pain which averaged 3-4/10 without radiculopathy.  Pain was described as a dull ache that occurred 1-2 times per week lasting for an hour, which was brought on by activity.  The physical exam showed no localized tenderness or guarding sever enough to cause an abnormal gait or spinal contour.  Muscle strength and sensory exams were normal for the lower extremities.  The ROM exam is summarized below.  The range of motion (ROM) examinations 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 ~7 Mos. Pre-Sep	NARSUM ~5 Mos. Pre-Sep	VA C&P 3 Days Pre-Sep	
Flexion (90 Normal)	90	70	75	
Combined (240)	>120, < 235	160	200	
Comment	Painful motion; tender; guarding with abnormal gait	Painful motion; tenderness	Painful motion	
§4.71a Rating	20%	10% (PEB 20%)	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under code 5241 (spinal fusion), citing limitation of combined ROM.  The VA assigned a 10% rating using an analogous code 5242 (degenerative arthritis of the spine) based on the VA C&P examination 3 days before separation, citing ROM criteria.  There was no evidence that thoracolumbar forward flexion approached a limitation of 30 degrees (or was ankylosed/frozen) to support any rating higher than 20%.  There was no associated radiculopathy for separate peripheral nerve rating.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no evidence of intervertebral disc syndrome resulting in incapacitating episodes requiring bed rest prescribed by a physician to warrant consideration of rating under the alternate VASRD formula based on incapacitating episodes due to intervertebral disc syndrome.  
After due deliberation, considering all of 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 spinal fusion condition.  

BOARD FINDINGS:  In the matter of the spinal fusion 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 20140714, 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 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160008011 (PD201403413)
	
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