RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00090
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20070813

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E-5, Explosive Ordinance Disposal Craftsman, medically separated for “chronic low back pain, status-post L4-5 foraminotomy and partial diskectomy” with a disability rating of 20%.  

CI CONTENTION:  He was given a higher rating for his conditions by the VA.  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 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 - 20070529	VARD - 20080214	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Back Pain…	5243	20%	Residuals of Surgery with Degenerative Disk Disease (DDD), Lumbosacral Spine	5243	20%	20071023	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent back surgery in June 2006 that completely relieved previous right lower extremity radicular symptoms.  Despite treatment, the back condition still could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred for an MEB.  The MEB forwarded “chronic low back pain” for PEB adjudication.  

At the time of the physical therapy (PT) clinic appointment on 1 November 2006 (9 months prior to separation and 4 months after surgery), the CI reported a chief complaint of back pain, with an improved pain level from 6/10 to 1/10 severity.  He could tolerate 20 minutes of aerobic exercise.  Radicular symptoms were denied.  The examination showed “major loss” of lumbosacral flexion, and “moderate loss” of extension and right lateral flexion.  Both sides of the iliolumbar region exhibited tenderness.  

At a pain clinic appointment on 7 December 2006 (8 months prior to separation, 5 months after surgery), the CI reported “fairly intense” low back pain that radiated into the posterior bilateral lower extremities, right greater than left.  Symptoms were worse with prolonged sitting and, at times, prolonged standing.  Additionally, he experienced bilateral tingling in his feet with prolonged sitting.  Examination showed somewhat flattened lumbar lordosis, and no antalgic gait.  Forward flexion to 20 degrees was accomplished “without increased pain.”  There were no other measurements provided, but extension and lateral bending was associated with increased pain.  Straight-leg raise (SLR) testing on the left caused increased buttock pain at 90 degrees.  SLR on the right was negative for nerve root impingement.  There was no lower extremity motor dysfunction, but an absent Achilles tendon reflex was present on the right.  A lumbar epidural steroid injection was administered.

The MEB NARSUM examination on 13 February 2007, 6 months prior to separation, noted complaints of chronic, daily back pain.  The physical examination showed unmeasured but “decreased ROM” and bilateral paraspinal tenderness.  SLR was negative for nerve root impingement bilaterally.  Lower extremity muscle strength was normal.  An MRI on 27 February 2007 documented mild disc protrusions at L3-L4 and L5-S1, and interval right L4 laminectomy with degenerative and fibrotic changes causing narrowing of the right aspect of the spinal canal and neural foramen.

A PT ROM assessment which was performed on 12 March, 2007 (5 months prior to separation) did not specify the method of measurement utilized.  It reported thoracolumbar flexion of “4 cm (normal 7.48 cm)” and extension of “4.2 cm (normal 5.05 cm).”  Left lateral flexion was 25 degrees, right lateral flexion 22 degrees, left rotation 30 degrees and right rotation 35 degrees (30 degrees normal for those 4 parameters).  At a neurology evaluation on 9 May 2007 the CI reported pain radiating to the plantar surface of each foot, but denied weakness.  The physical examination showed a normal gait and normal lower extremity muscle strength. Electrodiagnostic studies of the right and left lower extremities showed no evidence of ongoing denervation.  

At the VA Compensation and Pension (C&P) examination on 23 October 2007, performed 2 months after separation, the CI reported chronic low back pain without spontaneous flares.  He also complained of referred pain in the lower extremities, primarily on the right foot, with cramping, aching feeling in the buttocks and legs and the sciatic nerve areas.  The physical examination showed 45 degrees of flexion (90 normal) and 120 degrees of combined ROM (240 normal).  Pain occurred at the extremes of ROM and reportedly worsened on repetitive motion.  Tenderness was present.  SLR testing for possible nerve root impingement was negative.  Gait and lower extremity neurologic findings were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back pain condition 20% coded 5243 (intervertebral disc syndrome).  The VA also rated the lumbosacral spine condition at 20% under the same code, based on the VA C&P examination 2 months after separation, citing limitation of ROM.  In deliberating the available ROM measurements on which to base a rating recommendation, the Board considered that the service PT examination 5 months prior to separation did not provide goniometric ROM assessments of flexion and extension, as required by the VASRD.  The limited data provided by the pain clinic 8 months prior to separation could support a 40% rating for flexion less than 30 degrees.  However, because the C&P examination (performed 2 months after separation) provided a complete evaluation, was the most proximate exam to the time of separation, and was further removed from the time of surgery (thus more reflective of a healed state) it was assigned preponderant probative value by the Board.  The spine measurements from this exam warranted a 20% rating, but no higher, for flexion greater than 30 degrees but not greater than 60 degrees, or for combined ROM not greater than 120 degrees.  The Board also 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).  Finally, the Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy. Although radiculopathy was diagnosed prior to surgery, those symptoms resolved; but complaints of lower extremity radiating pain and intermittent foot tingling did recur.  However, electrodiagnostic testing did not show evidence of active radiculopathy.  While the CI may have experienced radiating pain from the back condition, 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 objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  The Board therefore concluded that an additional disability rating was not justified on this basis.  After due deliberation, and 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 condition.  

BOARD FINDINGS:  In the matter of the low back 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 20150128, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00090.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings