RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXX						          CASE:  PD-2014-04226
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20041022  

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Aircraft Armament Systems Journeyman) medically separated for “degenerative disk disease at L4-L5, L5-S1,” rated at 10%.

CI CONTENTION:  “Required two surgeries to temporarily fix issues.  Lower back required discectomy in 2004.  Still unable to move without difficulty.”   The applicant’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 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 confined to review of medical records and all available evidence for application of the 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:  

IPEB - Dated 20040804	VA* - (~10 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Disk Disease at L4-L5, L5-S1	5243	10%	Degenerative Disc Disease at L4-L5, L5-S1	5243	10%	20050822	
Other MEB/PEB Conditions x 1 (Not in Scope)	Other x 0	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20051003 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Degenerative Disk Disease at L4-L5, L5-S1.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in approximately 2001.  The CI denied any specific injury or trauma.  Radiographic studies in Jul 2002 showed disc herniation of lumbar spine L4-5 and L5-S1 and degenerative disc disease HNP and DDD).  The CI had continued back pain with pain radiating down her legs (mostly on the left).  Conservative pain management was not effective and there was no surgical indication.  The MEB NARSUM exam on 30 June 2004 (4 months prior to separation) noted complaints of chronic low back pain radiating down both legs with occasional numbness down the left leg.  The CI denied weakness.  Physical exam showed no focal neurologic deficits.  A consult for a second opinion for surgery was pending.  At the time of the spine specialties clinic appointment on 10 August 2004 (2 months prior to separation; and after the PEB date), the CI reported back pain of 5-10/10 with wakening at night 4-5 times and limited standing, sitting and walking times and distances.  She was taking narcotic pain reliever and muscle relaxant medications.  On examination the CI was “truncally deconditioned…” and could walk on heels and toes.  The back was tender to palpation.  Back range-of-motion (ROM) was recorded as 60 degrees flexion and extension 40 degrees with extension and rotation causing mild discomfort.  There was no weakness and sensory exam was normal.  Straight leg lifting caused back discomfort.  The specialist indicated that the CI was not a surgical candidate and added anti-inflammatory medication.  The examiner recommended another epidural steroid injection, weight loss and pelvic and trunk exercise program.  

At the VA Compensation and Pension (C&P) examination on 22 August 2005, performed 10 months after separation, the CI reported daily left-sided mid-back pain which frequently radiate to her left hip.  She had “bad days” where pain radiated down both legs and was associated with left leg numbness, tingling and occasionally weakness.  Symptoms were aggravated after prolonged standing, walking (over 2 blocks), or increased activity.  The CI indicated she could not exercise, stoop, bend, lift or carry and occasionally required help with climbing stairs.  Physical exam showed painful motion with forward flexion of 85 degrees and full extension, lateral rotation and side bending.  There was mild tenderness and occasional muscle spasm with a normal gait.  There was a positive straight leg raise on the left (for radiating symptoms).  There was normal strength except for 4/5 quadriceps extension and foot plantar flexion.  Reflexes and sensory exams were normal.  X-rays showed mild disc space narrowing at L4-L5.  MRI showed a right disc protrusion at L4-L5 which abutted the right S1 nerve root.  The record shows that the CI underwent back surgeries over 21 months remote from separation (August 2006, diskectomy right L6-S1; and March 2011, diskectomy right L4-L5).  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5243 code (intervertebral disc syndrome).  The VA also assigned a 10% rating using the 5243 code, citing painful limited motion and magnetic resonance imaging evidence.  However, the pre-separation specialist’s evaluation documented forward flexion of 60 degrees meeting the 20% rating criteria of “forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees.”  The Board adjudged that the specialist’s evaluation 2 months prior to separation had the highest probative value for rating as it was closest to the time of separation, and no other exams were significantly more detailed or comprehensive.  There was no evidence of intervertebral disc syndrome resulting in incapacitating episodes requiring bed rest prescribed by a physician to warrant consideration of rating under the alternate VASRD formula based on incapacitating episodes due to intervertebral disc syndrome.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI had herniated discs with radicular pain documented in the treatment records.  She also complained of occasional radiating numbness and associated weakness.  There were no fixed neurologic deficits.  The preponderance of examinations indicated normal strength, and the single exam indicating weakness did not document any focal weakness and assessed generalized truncal deconditioning.  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).”  There is no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  The Board therefore concludes that additional disability rating was not justified on this basis.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the low back (DDD at L4-L5, L5-S1) condition.  

BOARD FINDINGS:  In the matter of the low back condition, the Board unanimously recommends a disability rating of 20%, coded 5243 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration. 

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Degenerative Disk Disease at L4-L5, L5-S1	5243	20%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140330, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

Dear XXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-04226.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

Attachment:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR