RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04225
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090812

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E5, Light-Wheel Vehicle Mechanic, medically separated for “low back pain with right L5 radiculopathy” with a disability rating of 10%.  

CI CONTENTION:  His condition caused other problems beyond back pain.  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 - 20090611	VARD - 20080209	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain with L5 Radiculopathy	5243	10%	Spinal Stenosis with Congenital Factor and Degenerative Disc Disease	5243	40%	20071128	
			Chronic, Stable Radiculopathy, Right Lower Extremity Associated with Spinal Stenosis with Congenital Factor and Degenerative Disc Disease	8521	20%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Low Back Pain with Right L5 Radiculopathy.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain with right L5 radiculopathy (nerve root irritation or injury) condition began in 1991 after a back sprain.  He developed back pain with radiating symptoms while driving in April 2005.  The CI denied any specific injury or trauma.  Because of symptomatic spinal stenosis (spinal canal narrowing) and disc herniation, on 23 May 2005 the CI underwent a lumbar (L3-L4-L5-S1) laminectomy (excision of posterior vertebral body at lamina) and L4-5 discectomy (excision of all/part of intervertebral disc).  Lumbar spine diagnostic imaging (MRI) studies on 14 August 2007 showed L3-L5 postsurgical changes (laminectomy, spinectomy, and discectomy) and L4-L5 disc herniation with opportunity for contact with the left L5 and right S1 nerve roots.  Electrodiagnostic (EMG) studies on 29 August 2007 were positive for a chronic, stable L5 radiculopathy on the right and was negative for acute radiculopathy in the bilateral lower extremities.  A lumbosacral spine MRI on 1 April 2009 showed wide L4-S1 laminectomy defects, an L2-3 mass impinging on the left neural foramen (nerve root opening), an L4-5 bulging disc and spur formation impinging on the left neural foramen, and an L5-S1 bulging disc impinging on the right nerve root.  Despite treatment, the back 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 “chronic right L5 radiculopathy,” and “lumbar degenerative disc disease,” for PEB adjudication.  

At the 28 November 2007 VA Compensation and Pension (C&P) evaluation, performed 21 months before separation, the CI reported constant low back pain that radiated down his right thigh.  The pain was aggravated by over exertion of his back, standing up from a sitting position, and climbing stairs.  The pain was relieved by rest with his legs raised.  The pain prevented his normal functions and ability to move his back.  Physical examination showed an antalgic gait (assuming a gait or posture to lessen pain) and normal posture.  Sensation and deep tendon reflexes (DTRs) were normal and pathologic reflexes were absent.  Strength was normal (5/5) except for distal (L4, L5, S1) right lower extremity 4/5 strength.  The spine examination revealed an abnormal spinal contour and thoracic sacrospinalis spasm and tenderness.  There was no atrophy, weakness, or guarding.  The straight leg raise (SLR) test (assesses for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) was positive bilaterally.  There was additional loss of motion on repetitive use because of pain.  Thoracolumbar ROM was limited by pain with a flexion of 50 degrees (normal is 90).  

At the MEB examination on 31 March 2009, 4 months before separation, the CI reported low back pain rated as 3-5/10 with intermittent radiating pain across his buttocks.  The pain infrequently radiated down his posterior thighs bilaterally following an inciting incident such as his 3 year old child jumping into his arms.  He experienced tingling across the ball of his foot 2-3 times weekly.  The CI reported intermittent numbness of the perineum and anus for 6-7 months and 1 episode of fecal and urinary incontinence 3-4 months prior.  The pain was aggravated by walking following prolonged sitting.  The physical examination documented an antalgic gait.  The spine examination revealed tenderness to deep palpation of the lower lumbar region and upper right buttock.  There was no abnormal spinal contour, muscle spasm, or guarding.  The DTRs were normal except the left ankle DTR was absent.  Pathologic reflexes were absent except the Babinski (primitive reflex causing upturned toe) was equivocal on the left.  Bilateral lower extremity and perianal sensation was normal.  Anal sphincter tone was normal.  Strength was normal (5/5) except for bilateral foot and great toe dorsiflexion of 4/5 strength.  The SLR test was positive bilaterally.  Thoracolumbar ROM was limited by pain with a flexion of 80 degrees.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back pain with right L5 radiculopathy condition 10% coded 5243 (intervertebral disc syndrome), citing limitation of motion.  The VA rated the low back pain with right L5 radiculopathy condition 40% coded 5243 (intervertebral disc syndrome) and 20% coded 8521 (paralysis of external popliteal nerve [common peroneal]), based on the VA C&P examination 21 months before separation, citing limitation of forward flexion and moderate incomplete paralysis of foot movement.  Recognizing the temporal relationship to the date of separation, the board assigned little probative value to the C&P examination, and greater probative value to the MEB examination.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  Radiographic and electrodiagnostic studies supported some level of radicular nerve irritation or involvement, but physical examinations (physical medicine, PT, MEB NARSUM, and VA C&P) revealed no objective findings of radiculopathy that would impact duty performance.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have suffered additional pain from the 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).”  Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation-specific activities.  While there were subtle decrements in strength, there was no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  The Board therefore concluded that an additional disability rating was not justified on this basis.  The Board considered whether a higher rating (§4.7) was achieved by using the alternate rating formula based on incapacitating episodes due to intervertebral disc syndrome (IVDS).  Although the CI had intervertebral disc disease there were no incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  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 pain with right L5 radiculopathy condition.  

BOARD FINDINGS:  In the matter of the low back pain with right L5 radiculopathy 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 20140221, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXX AR20160013849 (PD201404225)

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