RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03701
BRANCH OF SERVICE:  NAVY 		SEPARATION DATE:  20050505

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6, Legal Clerk, medically separated for “status post lumbar microdiscetomy” with a disability rating of 20%.

CI CONTENTION:  “Please consider all conditions.”  Her 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:

SERVICE PEB - Dated 20050203	VARD - 20051109	
Condition	Code	Rating	Condition	Code	Rating	Exam	
S/P Previous Lumbar Microdiscetomy	5237	20%	S/P L4-L5 Microdiscetomy	5243	20%	20050406	
			S/P L4-L5 Microdiscetomy with Residual Scar	7804	10%	20050406	
Severe Back Pain	Cat II					
Left Lower Extremity Pain	Cat II	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA RATINGS:  40%	

ANALYSIS SUMMARY:

Low Back Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the low back pain (LBP) condition began approximately 9 years prior to MEB referral.  Lumbar spine diagnostic imaging (MRI) showed slight L4-L5 disk degenerative changes, L4-L5 and L5-S1 bulging disks, no significant effacement on bilateral nerve roots, no neural compromise, and no spinal stenosis.  At a 14 April 2004 neurosurgery consultation the CI complained of recent onset of right leg pain down to the toes and heel.  The bilateral straight leg raise (SLR) tests (assess for herniated disk causing sciatic nerve root [L5-S1] radiculopathy) were positive.  The diagnoses listed lumbar disk degeneration and displacement.  At an 8 June 2004 preoperative evaluation the CI complained of recurrent LBP exacerbations (1995/2002/2004).  The CI reported worsening symptoms of LBP with radiation of tingling and numbness to the bilateral legs since January 2004.  The physical examination documented a normal gait.  The lumbosacral spine examination revealed tenderness and decreased range of motion (ROM).  The SLR tests were positive and there was no evidence of acute motor or sensory deficits.  The diagnosis listed lumbar disk disease, disk degeneration, and disk displacement with radiculopathy (nerve root irritation or injury).  On 9 June 2004, the CI underwent L4-L5 microdiscetomy for lumbar radiculopathy secondary to a left L4-L5 disk protrusion compressing the nerve root.  A postoperative lumbar spine X-ray was normal.  A 15 November 2004 lumbosacral MRI showed epidural fibrosis (connective tissue scarring and thickening) status post left laminectomy at L4-L5 without recurrent herniation or neural foraminal (nerve root opening) comprise.

The 23 December 2004 MEB NARSUM by neurosurgery, 5 months before separation, recounted the history and interventions.  The CI reported doing extremely well after the surgery for approximately 2 months.  She the noted the symptoms began to progressively return with increasing severity.  “She describes her pain as 50% low back, 50% left lower extremity.”  The CI complained deep aching LBP with associated intermittent left buttock pain that radiated to the posterolateral thigh and lateral lower leg and foot.  Symptoms were exacerbated by activity and interfered with work and sleep.  She denied bowel or bladder dysfunction.  The physical examination documented a normal gait and being able to walk on heels and toes.  The spine examination revealed a very well healed incision and no tenderness.  The ROM was “completely normal” in flexion, extension, and lateral maneuvers.  The crossed straight leg raise (XSLR) tests (assess for herniated disk causing sciatic nerve root [L4-L5-S1] radiculopathy) were negative and the SLR test was positive on the right.  Motor strength (5/5) was normal.  Sensation (light touch) was normal except for minimal touch causes severe pain and discomfort on the left S1 dermatome (area of skin sensation from a single nerve root).  The neurosurgeon interpreted the MRI as showing no recurrent disk herniation and a significant amount of surgical tract scarring and fibrous tissue which appeared to be compressing the left L5 nerve root.  The diagnosis listed severe back pain and left lower extremity pain status post lumbar microdiscetomy.  At a 5 January 2005 pain management evaluation the CI reported she developed back pain, and subsequent resumption of left radicular pain, in October 2004.  The dysesthesia (abnormal sensation) and 4-7/10 pain were most pronounced at night.  Symptoms were exacerbated by left lateral leg contact and interfered with sleep.  Symptoms were improved with standing.  She denied bowel or bladder incontinence.  The physical examination documented a normal gait and normal heel and toe walking.  The lumbar spine examination revealed a normal appearance with tenderness, trigger points (tender loci which refer pain), and spasm.  The ROM was flexion of 90 degrees (90 normal) and extension of 40 (30 normal).  The SLR tests were negative.  Motor strength and deep tendon reflexes were normal.  There was allodynia (pain from stimuli which are not normally painful), and hyperpathia (exaggerated pain from painful stimuli), over the S1 > L4 and L5 dermatomes.  The examiner recounted the findings of the MRI.  The diagnosis listed postsurgical scar tissue impingement with left radiculopathy.

The 6 April 2005 VA Compensation and Pension (C&P) examination, 1 month before separation, recounted the history and interventions.  The CI reported resolution of her symptoms for 3 months after surgery and then had a sudden unprovoked onset of recurrent left lower extremity radicular pain.  The back symptoms were similar to before the surgery, but she denied episodes of sudden weakness.  Symptoms were exacerbated by prolonged sitting, activity, sexual intercourse, stooping, bending, and lifting and incompletely relieved with medications.  She complained of some itching and mild discomfort of the surgical scar.  The physical examination documented the CI walked without a limp or assistive device and was able to walk on heels and toes.  The back examination revealed a mildly hyper pigmented and minimally tender and raised laminectomy scar (4 cm x 0.5 cm).  The superficial scar was without loss of underlying tissue.  The spine examination revealed a somewhat exaggerated lordosis (anterior spine curvature) and mild left paralumbar tenderness and spasm.  The ROM was flexion of 90 degrees, extension of 30, bilateral lateral bending of 30 (30 normal), and bilateral rotation of 30 (30 normal) degrees.  There was no further loss of motion or function caused by pain, fatigue, weakness, or lack of endurance following repetitive use.  The XSLR and SLR tests were positive on the left.  Sensation and 2+ deep tendon reflexes were normal and equal except for 1+ patellar deep tendon reflexes.  The examiner recounted the findings of the MRI.  The diagnosis listed status post lumbar laminectomy with L4-L5 microdiscetomy and residual left lower extremity radiculopathy secondary to epidural fibrosis.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 20%, coded 5237 (lumbosacral strain).  The related Category II diagnoses of left lower extremity pain and severe back pain are intrinsic to the rated unfitting Category I low back condition.  Separate pain ratings cannot be supported without pyramiding (VASRD §4.14); thus, they are appropriately subsumed in the same rating.  The VA also rated the low back condition 20%, coded 5243 (intervertebral disk syndrome) based on the VA C&P examination 1 month before separation, citing paralumbar tenderness and spasm, exaggerated lordosis, and sensory deficits.

The Board agreed the ROM values in the proximate (MEB NARSUM and VA C&P) examinations did not attain the minimum 10% rating based upon the general rating formula for diseases and injuries of the spine.  While the CI may have suffered intermittent left lower extremity radicular pain, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  The critical decision is whether or not there was significant motor weakness which would impact military occupation specific activities.  There was no evidence that motor weakness or sensory loss existed to any degree that could be described as functionally impairing.  The Board therefore concluded that additional disability rating was not justified on this basis.  While the pain management examination documented lumbar normal appearance, tenderness, and spasm, and the VA C&P examination documented a somewhat exaggerated lordosis and mild left paralumbar tenderness; however, there was no muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour.  Other routes to a rating higher than the PEB’s 20% were considered, but there was no evidence of additional functional loss from repetitive use to warrant application of VASRD §4.45, and no evidence of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disk disease.  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 status post lumbar microdiscetomy 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 20140702, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 20 Oct 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN