RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00111
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090913

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Wheeled Vehicle Mechanic, medically separated for “low back pain secondary to spondylolysis,” with a disability rating of 10%.

CI CONTENTION:  “Please consider 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 – 20090421	VARD - 20130814	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain Secondary to Spondylolysis	5239	10%	Spondylolisthesis	5239	20%	20130716	
			Radiculopathy, Right Lower Extremity	8726	10%	20130716	
			Radiculopathy Right Lower Extremity	8726	10%	20130716	
Adjustment Disorder	Not Unfitting	Adjustment Disorder with Depressed Mood	9440	30%	20130711	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Low Back Pain Secondary to Spondylolysis.  According to service treatment records (STR) and the medical evaluation board (MEB) narrative summary (NARSUM), the low back pain (LBP) began on a ruck march in basic training approximately 3 years prior to referral for MEB.  A 14 April 2008 lumbar spine X-ray showed a possible L5 spondylolysis (fracture/degeneration/deficient development of vertebral pars interarticularis) with Grade I L5 on S1 anterior spondylolisthesis (displacement of vertebra after pars interarticularis fracture).  The degree of slippage in spondylolisthesis is classified as percentage of the cephalad vertebral body that extends beyond the anterior border of the caudal vertebral body (Grade I < 25%).  Lumbar spine diagnostic imaging (MRI) showed lumbar spine spondylosis (spine degenerative disease), bilateral L5 spondylolysis with Grade I L5 on S1 anterior spondylolisthesis, and mild to moderate L5-S1 (L>R) foraminal (nerve root opening) stenosis (narrowing) caused by a disc osteophyte complex.  At a 7 July 2008 orthopedics encounter the CI complained of 2 years of LBP with occasional right lower extremity (LE) tingling.  He denied LE weakness, groin numbness, and bowel or bladder dysfunction.  The physical examination documented a normal gait and lower central tenderness.  Lumbosacral spine motion was abnormal with pain elicited at the extreme limits of active range of motion (ROM).  The Patrick tests (assess hip and sacroiliac [SI] joint pathology) were positive at the SI joints.  The straight leg raise (SLR) tests (assess for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) were negative.  Strength, sensation, and deep tendon reflexes (DTRs) were normal and pathologic reflexes were absent.  The examiner recounted the findings of the MRI.  The assessment listed congenital (inborn physical abnormality or disease) lumbosacral spondylolysis, congenital Grade I spondylolisthesis, L4-L5 and L5-S1 herniated discs, and lumbago (lumbar back pain).  The CI underwent a series of four bilateral L-5 pars interarticularis injections with local anesthetic and corticosteroid between June 2008 and March 2009.  A 27 August 2008 lumbar spine flexion and extension X-ray showed continued Grade I anterior L5 spondylolisthesis without significant change in alignment or evidence of instability.  A 24 November 2008 lumbar spine X-ray showed a Grade I L5 on S1 spondylolisthesis with nearly complete loss of the disk space.  On 2 March 2009 the CI underwent a lumbar epidural steroid injection (ESI).  On 10 March 2009, physical therapy (PT) measured ROM with a goniometer for the MEB.  The CI complained of constant 6/10 low back pain which increased to 9/10 with movement.  He reported intermittent tingling into the right LE to the knee and occasionally to the mid-calf.  The physical examination documented no antalgic (assuming a gait or posture to lessen pain) gait and no assistive device.  The thoracolumbar spine examination revealed tenderness over the central L3, L4, L5 area with no spasm, guarding, abnormal spinal contour, deformity, muscle atrophy, swelling, or scarring.  Pain-limited (flexion/extension) repetitive active ROM was flexion of 60 degrees (90 normal), extension of 10 degrees (30 normal), left lateral flexion of 30 degrees (30 normal), right lateral flexion of 25 degrees (30 normal), and bilateral rotation of 30 degrees (30 normal), and combined ROM of 185 (240) degrees.  

At the 16 April 2009 NARSUM, 5 months before separation, the CI complained of daily 5/10 LBP with radiation into the right hip and LE to the knee.  Pain was exacerbated to 8-10/10 with unusual positions, prolonged standing, lifting, load bearing, sit-ups, pushups, running, moderate activity, or impact activities and incompletely relieved with medication (Percocet).  The CI was not a surgical candidate.  He did not experience significant improvement from non-operative management which included activity modification, chiropractic manipulation, PT, transcutaneous electrical nerve stimulation (TENS) unit (non-invasive nerve stimulator to reduce pain), pars interarticularis injections, lumbar ESI, and medication.  The physical examination documented a normal gait.  The thoracolumbar spine examination revealed L4 to S1 tenderness, a normal appearance, and no muscle spasms.  “There was a mild reduction in the range of motion of the thoracolumbar spine clinically, and there was pain with full flexion and with extension.”  The examiner cited the PT for MEB ROM and subjective findings.  “Straight leg raising was painful on the left and on the right at 60 degrees.”  Strength, sensation, and DTRs were normal and pathologic reflexes were absent.  The diagnosis listed chronic LBP secondary to spondylolysis and a Grade I L5 on S1 spondylolisthesis. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10%, coded 5239 (spondylolisthesis or segmental instability) citing forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees.  The VA assigned a 20% rating under the 5239 code (spondylolisthesis or segmental instability) based on the VA C&P exam 4 years after separation,  citing forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees.  The Board agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) reported on the NARSUM examination.  While diagnostic imaging consistently showed Grade I spondylolisthesis, this represents the least severe percentage of slippage under the grading classification for consideration under 5239.  The 27 August 2008 lumbar spine flexion and extension X-ray showed no significant change in alignment or evidence of instability for consideration of segmental instability under 5239.  While proximate examinations documented tenderness, there was no evidence of muscle spasm, abnormal spinal contour, or abnormal gait.  While the CI may have complained of intermittent pain radiating into the right LE, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  The critical decision is whether or not there was significant motor weakness which would impact military occupation specific activities.  There was no evidence that motor weakness or sensory loss existed to any degree that could be described as functionally impairing.  The Board therefore concluded 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 condition, coded 5239.

Contended PEB Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that the adjustment disorder with depressed mood was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  The adjustment disorder with depressed mood condition was reviewed and considered by the Board.  There was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance.  After due deliberation 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 adjustment disorder with depressed mood condition and so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the low back condition, the Board unanimously recommends a disability rating of 20%, coded 5239 IAW VASRD §4.71a.  In the matter of the contended adjustment disorder with depressed mood 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Low Back Pain Secondary to Spondylolysis 	5239	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140727, 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

20 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160017972 (PD201500111)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA