RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03943
BRANCH OF SERVICE:  Army				           SEPARATION DATE:  20051109

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Multichannel Transmission Systems Operator-Maintainer, medically separated for “chronic subjective back pain, status post L5-S1 fusion” with a disability rating of 10%.

CI CONTENTION:  Contends his unfitting back condition and other VA conditions not identified by the MEB or PEB.  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 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 - 20050909	VARD - 20060831	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Subjective Back Pain	5241	10%	Status Post L5-S1 Fusion	5241	10%	20060816	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Chronic Subjective Back Pain, Status Post L5-S1 Fusion.  According to service treatment record (STR) and the MEB narrative summary (NARSUM) the CI’s low back pain gradually began in November 2003 without injury or trauma.  Diagnostic imaging revealed single-level degenerative disc disease about the lumbar spine with vertebral slippage.  On 25 June 2004, the CI underwent a low lumbar spinal fusion.  Despite extensive rehabilitation his back pain remained.  He was given a L3 profile and referred to a MEB.  The MEB forwarded chronic low back pain status post anterior and posterior spinal fusion of L4-S1 for PEB adjudication.

At the MEB NARSUM examination on 17 July 2005 (4 months prior to separation), the CI reported continued 2/10 scaled low back pain at rest.  He denied radicular pain or altered sensation into his lower extremities.  His physical examination revealed a normal appearing gait and posture.  The thoracolumbar spine range of motion (ROM) was normal except extension at 15 degrees (normal 30); painful motion was not addressed.  There was no spinal tenderness with distal neurologic parameters intact.

At the VA Compensation and Pension (C&P) examination on 16 August 2006 (9 month after separation), the CI reported low back pain at 6/10 pain when aggravated by bending, stooping, lifting, prolonged sitting, running, or twisting.  The physical examination revealed bilateral lumbar spasms and straightening of the lumbar spine.  Thoracolumbar ROM was normal except for forward flexion at 60 degrees (normal 90) with painful motion.  Distal sensation was intact and the right-sided patellar reflex was absent (provider indicated that the absent reflex was due to residual of a right L-5 radiculopathy).  “[The CI] does have a residual right L-5 radiculopathy occasionally causing very fleeting shooting pains in the right anterior lateral thigh, which really do not affect his activities and are not treated with medication.”

The Board directed its attention to its rating recommendation based on the above evidence.  Both the PEB and VA rated the back pain condition 10%, coded 5241 (spinal fusion).  The VA based its rating on the C&P examination 9 months after separation, citing limited painful motion.  Board members agreed that the totality of the STR was indicative a 10% spine based on ROMs as compared to the C&P ROM examination, 9 months after separation, which supports a 20% rating.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  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 back pain condition.

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI reported symptoms of radiating pain documented in the STR; however, examinations indicated normal strength, reflexes and gait, and the sensory changes did not affect his occupation.  While the CI may have suffered pain into his extremities from a nerve involvement, 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 in this case that motor weakness significantly interfered with satisfactory duty performance at separation and could not be recommended for additional disability rating.

BOARD FINDINGS:  In the matter of the chronic subjective back pain 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 20140908, 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

29 NOV 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
 (PD201403943)

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