RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03441
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20021113

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Signal Support Specialist, medically separated for “lower back pain with MRI showing L4/L5 and L5/S1 degenerative disc disease with disc protrusion but no foraminal stenosis and no impingement,” with a disability rating of 10%.

CI CONTENTION:  “He was rushed through the process by the VA representative at Landstuhl Army Hospital and many issues he brought up were dismissed.  His lower back condition continues to affect his daily life.  He was not rated for his thoracic and cervical back regions.  His neck pain causes migraines for which he receives treatment.  His years of jump status, difficult assignments requiring high levels of physical fitness, or deployed locations (exposure to burning feces and garbage) were not considered.”  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 - 20020723	VARD - 20021218	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lower Back Pain with MRI Showing L4/L5 and L5/S1 Degenerative Disc Disease with Disc Protrusion but No Foraminal Stenosis and no Impingement	5299-5295	10%	Lumbar Spine Degenerative Disc Disease	5292	20%	20021016	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Lower Back Condition.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s lower back pain condition began in June 1990 when he complained of back pain after throwing a heavy object.  Diagnostic imaging studies (X-rays) 14 March 2001 showed minimal spurring of the anterior aspect of L2 vertebral body.  No other significant findings were seen.  Magnetic resonance imaging (MRI) studies 2 May 2001 showed normal alignment with mild degenerative disc disease.  There was a small disc bulge at the L5 level without narrowing of the neuroforamina (nerve root opening).  There was a broad based disc bulge at L5-S1 level with no stenosis (narrowing) and no impingement on nerve structures.  An MRI on 15 August 2001 showed degenerative disc disease at L4-5 and L5-S1 with a bulging intervertebral disc at L4-5.  Lumbar spine diagnostic imaging (CT) showed an L4-5 disc prolapse and a mild L5-S1 disc protrusion with no neuroforaminal stenosis.  A pelvis MRI showed unremarkable soft tissues and bones with no evidence of an intra-pelvic or sacral tumorous process.  At a 24 September 2001 neurosurgery second opinion, the CI complained of recurrent lumbago (lumbar back pain) with sciatica (radiating pain along sciatic nerve distribution) since 1993.  He complained of more pronounced symptoms with glutealgia (buttocks pain), intermittent radiation to the legs (consistent with dermatome L3 bilaterally), rectal incontinence, and coital problems due to pain since March 2001.  He denied subjective sensorimotor deficits.  The physical examination revealed tenderness at the lower lumbar spine and bilateral sacroiliac (SI) joints.  The straight leg raise (SLR) test (assess for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) and reverse SLR test (assesses for herniated disc causing femoral nerve root [L2-L4] radiculopathy) were negative.  Strength, sensation, and deep tendon reflexes (DTRs) were normal and pathologic reflexes were absent.  The rectal examination revealed normal sphincter tone and unremarkable morphology and rectoscopy revealed no abnormalities.  The examiner reported the lumbar spine CT showed no evidence of a space-occupying mass which would be an indication for surgery and the pelvic MRI was unremarkable.  The neurosurgeon documented “The patient's complaints and in particular the rectal incontinence cannot be explained from a neurosurgical point of view.  The lumbago with sciatica does not present an indication for surgery.  We recommend continued conservative measures.”  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “lower back pain” for PEB adjudication.  The 12 June 2002 MEB NARSUM exam, 5 months prior to separation, noted complaints of low back pain that was unresponsive to years of treatment.  Physical examination showed tenderness of the lower lumbar spine and bilateral SI joints.  There was a normal gait and provocative maneuvers for signs of radiculopathy or radiating pain due to spinal nerve root or sciatic nerve involvement were negative.  Back ROM was normal with pain occurring at 80 degrees flexion and less than 5 degrees extension.  Strength, sensation, and DTRs were normal and pathologic reflexes were absent.  At the 16 October 2002 VA Compensation and Pension (C&P) examination the CI reported constant low back pain rated 3/10 scale increasing to 10/10 with activity.  He complained of significant stiffness in the morning and that lifting and bending aggravated the pain.  The pain was not affected by standing or walking and medication (Flexeril and Percocet) relieved the pain.  Since March 2001, the CI reported 2 instances of stool urgency with leakage before he could get to a bathroom.  He denied bladder changes.  Physical examination showed no muscle spasm or tenderness, and gait, spinal contour, and reflexes were normal.  Back ROM was full with some pain on bending and extension.  The SLR and Patrick (assesses hip and SI joint pathology) tests were negative.  The rectal examination revealed good sphincter tone.  Strength, sensation, and DTRs were normal and pathologic reflexes were absent. The examiner documented “The veteran had an instance of the need to defecate and was unable to leave formation to attend himself and therefore leaked stool on two occasions.  This does not constitute rectal incontinence associated with a neurological back issue.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the lower back pain condition 10% coded 5299-5295 (lumbosacral strain), citing painful motion.  The VA rated the lower back pain condition 20% coded 5292 (limitation of motion lumbar spine), based on the VA C&P examination 1 month before separation, citing moderate limitation of motion of the lumbar spine, or demonstrable deformity of a vertebral body from fracture with slight limitation of motion.  In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation.  The Board noted that the 2001 VASRD standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards in 2004.  The Board must correlate the above clinical data with the 2001 rating schedule and applicable diagnostic codes.  There was no vertebral fracture (5285), complete spine ankylosis (5286), lumbar spine ankylosis (5289), or limitation of lumbar spine motion (5292) for consideration under the respective codes.  While there was SI joint tenderness, there was no sacro-iliac injury/weakness (5294) for consideration under the respective code.  While there was L4-5 disc prolapse and a mild L5-S1 disc protrusion by imaging, there was no neuropathy, characteristic pain, muscle spasm, absent DTR, neurological findings appropriate to disc site, or recurring attacks for consideration under intervertebral disc syndrome (5293).  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  There was no evidence that the 2 instances of stool urgency with leakage represented the sequelae of radiculopathy.  While the CI reported intermittent pain radiating to his legs and numbness, exams indicated normal strength, reflexes, and gait, and the sensory changes did not affect his job.  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 objective evidence of a radiculopathy with functional impairments such as weakness with a direct impact on fitness that were separately functionally impairing for duty.  The Board therefore concluded that additional disability rating was not justified on this basis.  Board members agreed that the symptoms more closely approximated the 10% rating (characteristic pain on motion) than 20% rating (muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position) under lumbosacral strain (5295).  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  

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 low back condition.  

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.  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 20140721, with attachments
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 
XXXXXXXXXXXXXXXXXX, AR20160017189 (PD201403441)

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