RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03458
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20031119

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Security Forces Journeyman, medically separated for chronic lower back pain [LBP] secondary to herniated nucleus pulposus at T12-L1, status post fusion and laminectomy (x2),” with a disability rating of 10%. 

CI CONTENTION:  The CI’s condition continues to worsen and negatively impacts daily activities.  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 based upon a 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:  

 COMBINED PEB - 20030923	VARD - 20040522   	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP …	5295	10%	Residuals, Discectomy and fusion T12-S1	5241	30%	20040305	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic LBP.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was first seen for LBP on 20 September 2001 when he noted a 2-year history of LBP now aggravated by an injury 2 weeks previously.  Conservative treatment (medications, duty modifications, etc.) did not relieve his symptoms and he underwent an anterior discectomy and fusion for a herniated disk at T12-L1 on 3 June 2002 with surgical revision on 27 October 2002.  His pain persisted after surgery and a series of steroid injections were performed with temporary relief.  He was seen in neurosurgery on 25 July 2003, 4 months prior to separation and 9 months after the second surgery, and noted to have persistent pain.  However, the neurological examination, gait, and range of motion (ROM) were all normal.  The CI noted subjective sensory deficits though which were not reproduced on examination.  His gait was noted to be cautious (he protected his back).  Additional surgery was not recommended.  The MEB forwarded “back pain: herniated nucleus pulposus at T12-L1 s/p fusion and laminectomy” for PEB adjudication.  The MEB NARSUM examination was dated 8 September 2003, 3 months prior to separation, noted complaints of persistent LBP.  Radiation of the pain to the left leg was noted to be improved.  On examination, the ROM of the back was normal as was the motor examination and reflexes.  Provocative testing for nerve root irritation was negative.  At the VA Compensation and Pension (C&P) evaluation, performed on 5 March 2004, 4 months after separation, the CI reported ongoing LBP and leg pain.  His posture was erect and gait steady without the use of an assistive device.  The ROM was reduced with flexion at 70 degrees (VA normal is 90) and a combined ROM of 215 (VA normal is 240).  Motion was painful, but not further reduced with repetition.  Sensation was noted to be reduced in both legs, more so on the left, but without further specification.  The motor function was 4/5 in both arms and legs; this was not explained.  The reflexes were normal.  Spasm was not present.  Incapacitation was not present.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5295 (an older code for lumbosacral strain; 5237 is the current code).  The VA rated the back condition 30%, coded 5241 (spinal fusion), based on the VA C&P examination 4 months after separation, citing functional loss and painful motion and that the CI reported the use of a cane.  A review of the VA C&P shows that the CI reported the use of a cane in 2002, but not at the time of the examination.  The Board reviewed the evidence.  Painful motion and the limitation in motion each support a 10% rating.  The gait was normal as were the ROM and neurological examination on multiple examinations.  The VA C&P noted sensory and motor deficits, but these were not attributed to a radiculopathy.  The basis for the 30% rating adjudicated by the VA is not clear from the records in evidence.  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 chronic low back pain condition.  

BOARD FINDINGS:  In the matter of the chronic low 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 20140521, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-03458.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings