RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04135
BRANCH OF SERVICE: navy  	SEPARATION DATE:  20090930

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Aviation Structural Mechanic, medically separated for “chronic cervicalgia,” with a disability rating of 20%.

CI CONTENTION:  The CI requests consideration of all conditions.  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:  

SERVICE PEB - 20090706	VARD - 20100206	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Cervicalgia	5241	20%	Degenerative Arthritis of the Cervical Spine	5242	0%	20090828	
Cervical Disc Herniation, Status Post Anterior Cervical Discectomies and Fusions	Cat II					
Thoracic Disc Herniations	Cat III	Degenerative Arthritis of the Thoracic Spine	5003	10%	20090828	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Cervicalgia.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), in November 2008 the CI had neck pain with bilateral positional numbness of the fingertips and underwent cervical spine surgery with discectomy and fusion at the C5-C6 and C6-C7 levels due to intervertebral disc herniation.  Following the surgery the upper extremity (UE) symptoms were improved, but the CI reported persistent neck and upper back pain.  Despite treatment, the cervical spine condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “cervicalgia” and “other and unspecified disc disorder of cervical region” for PEB adjudication.

The MEB NARSUM examination on 28 April 2009, 5 months prior to separation, noted complaints of intractable neck pain.  Physical examination showed range of motion (ROM) as forward flexion of 60 degrees (45 normal), with a combined ROM of 275 degrees (normal 340 degrees).  The CI had a negative Spurling’s test for radicular pain and negative Hoffman’s test for cervical spinal cord compression (myelopathy).  Upper extremity strength and reflexes were normal.  Cervical spine X-rays showed post-surgical changes and well maintained disc spaces.

At the 28 August 2009 VA Compensation and Pension (C&P) examination, performed 1 month before separation, the CI reported constant neck pain that radiated to both UEs, with symptoms of stiffness, fatigue, spasms, decreased motion, paresthesia, and numbness, without bowel or bladder problems.  The CI stated that his condition had not resulted in any incapacitation and reported all activities were limited due to the cervical fusion and residual pain.  Physical examination showed a normal posture and the CI walked with a normal gait.  There was no evidence of radiating pain on movement, no muscle spasm, no tenderness, no guarding, no weakness, no loss of tone, and no atrophy of the limbs.  There was no ankylosis of the cervical spine and the CI had full neck ROM and there was no additional limitation due to pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 20% using code 5241 (spinal fusion).  The VA assigned a 0% rating using code 5242 (degenerative arthritis of the spine) citing no evidence of ratable criteria.  There was no limitation of cervical spine motion to support a rating higher than 20% given by the PEB, under the General Rating Formula for Diseases and Injuries of the Spine.  There was no cervical ankyloses or evidence of additional functional loss that would impact functioning.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula, or evidence of ratable peripheral nerve impairment at separation which would provide for additional rating.  

The Navy PEB also listed “cervical disc herniation, status post anterior cervical discectomies and fusions” as a related Category II condition (a condition which contributed to the primary unfitting condition but was not separately ratable).  The impairment from the “cervical disc herniation, status post anterior cervical discectomies and fusions” was properly subsumed under the overall rating for the “chronic cervicalgia” IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The Board concluded there was no evidence to support higher or additional rating for the cervical spine condition.  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 cervicalgia” condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that Category III condition of “thoracic disc herniation” was not unfitting.  The CI was treated for upper back and neck pain and a thoracic MRI on 9 August 2008 showed “mild degenerative disc disease.”  The CI was treated with six epidural steroid injections of the thoracic spine without relief of his upper back pain.  He underwent cervical spine surgery in November 2008, which also did not relieve his upper back pain.  Both limited duty boards in record indicated diagnoses of the cervical spine and the thoracic spine.  The commander’s statement did not note specific medical diagnoses, stating the CI’s “medical condition does not allow him to be assigned to a sea duty command or work on aircraft and the MEB forwarded “thoracic sprain” for PEB adjudication.  However, the NARSUM examination noted full ROM of the low back with normal lower extremity (LE) strength and sensation.  Following multiple treatment interventions, there was no performance-based evidence from the record that the thoracic spine condition significantly interfered with satisfactory duty performance at the time of separation.  A pre-separation C&P examination also showed a normal examination of the thoracolumbar spine, without tenderness or muscle spasm and normal LE strength, sensation, and reflexes.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, therefore no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the “chronic cervicalgia” condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended “thoracic disc herniation” condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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, 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 11 Aug 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:

		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN