RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00123
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20081027

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Aircraft Armament Systems Journeyman, medically separated for “chronic neck pain with cervical facet syndrome” with a disability rating of 20%.

CI CONTENTION:  The CI contends his unfitting neck condition continues to worsen and negatively impacts daily activities. He also contends conditions not identified by either the MEB or PEB.  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 – 20080821	VARD – 20091006	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain with Cervical Facet Syndrome	5242	20%	Degenerative Disc Disease, Cervical Spine, with Facet Syndrome and Radiculopathy	5239	20%	20090810	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Neck Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck pain condition insidiously began in late 2005.  Cervical spine x-rays were normal.  Despite aggressive physical therapy (PT) and multiple local epidural steroid injections, his painful symptoms remained.  Although denying radiculopathy symptoms, the CI brought forth medical history documents that “suggested a C-8 radiculopathy”.  Rehabilitation did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “cervical radiculopathy” for PEB adjudication.
At the MEB NARSUM examination on 20 February 2008 (8 months prior to separation) The CI complained of continued neck pain.  His physical examination (PE) revealed full active range of motion (ROM) of the cervical spine with tenderness about muscles adjacent to the cervical vertebra.  The diagnosis remained unchanged.  A PT clinic appointment on 6 May 2008 (6 months before separation), the examiner recorded complains of constant throbbing ache on posterior cervical spine.  On PE, there was decreased and painful motion.  Forward flexion was 30 degrees (normal 45), 25 degrees of bilateral flexion (normal 45), and 35 degrees of bilateral rotation (normal 80).  The case file contained two pain management encounters dated June and July 2008 (4 and 3 months prior to separation) which noted, “[The CI] has constant severe left sided neck pain.”  At the 10 August 2009 VA Compensation and Pension (C&P) evaluation, performed 9 months after separation, the CI reported a constant and severe neck pain without associated stiffness, spasms, decreased motion, numbness, or weakness.  The CI stated, “…condition has not resulted in any incapacitation” and “…he does not experience any overall functional impairment from this condition.”  His neck-focused PE was normal with full ROM.  There was no comment with regards to painful motion.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 20% under VASRD code 5242 (degenerative arthritis), citing activity restrictions.  The VA also assigned a 20% rating using code 5239 code (spondylolisthesis or segmental instability) citing constant and severe pain.  The Board agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 15 degrees but not greater than 30 degrees) reported on the 6 month pre-separation PT examination.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in 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 neck pain condition.

BOARD FINDINGS:  In the matter of the neck pain 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 modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150110, 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-2015-00123.

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