RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00168
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20070725

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Intelligence Applications Craftsman, medically separated by the Formal Physical Evaluation Board (PEB) for “low back pain” with a disability rating of 20%.  

CI CONTENTION:  The CI contends her back condition and any other conditions that occurred while on active duty.  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 - 20070427	VARD – 20080317	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain Due to DDD s/p L5-S1 Fusion w/Disc Spacer	5241	20%	Post Fusion L5-S1 w/Lumbago	5241	20%	20080128	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Low Back Pain due to Degenerative Disc Disease (DDD) Status Post (S/P) L5-S1 Fusion with Disc Spacer.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain condition began in January 2005 after sneezing while running during physical training.  Imaging studies in April 2005 and December 2005 showed minimal DDD at the L3-L5 levels, and a diffuse L5-S1 disc bulge with mildly narrowed neural foramina.  Due to failure of conservative treatment to manage ongoing pain, L5-S1 fusion with discectomy was performed in February 2006.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty, and an MEB was initiated.  The MEB forwarded “chronic low back pain s/p back surgery” for PEB adjudication.  

The MEB NARSUM examination on 23 January 2007, 6 months prior to separation, noted complaints of chronic low back pain described as aching, with episodic pain in her hips and legs, for which she took narcotic pain medication.  She could not run or perform sit-ups or push-ups. She could drive and perform light housework.  The physical examination showed full range of motion (ROM) in flexion, but marked pain and limitation in extension.  No measurements were provided and other ROM parameters were not assessed.  Gait and lower extremity muscle strength were normal, and there was no tenderness of the spine.  A recent X-ray reportedly showed mild degenerative changes and stable post-operative hardware.  

A physical examination by a pain specialist on 4 May 2007, 3 months prior to separation, showed decreased active (but unmeasured) ROM due to pain.  Moderate paraspinal muscle tenderness was present, but spinal curvature was normal and muscle spasm was absent.  A test for nerve root irritation was negative.  Review of the STR found no evidence of physician-prescribed bedrest for the back condition during the year prior to separation.  

At the 28 January 2008 VA Compensation and Pension (C&P) evaluation, performed 6 months after separation, the CI reported chronic low back pain which radiated to both lower extremities and was associated with lower extremity numbness and tingling, but not weakness. The back condition prevented her from walking more than 1-3 miles.  The CI reported that during the previous 12 months she experienced incapacitating episodes “2-3 times per month.”  The physical examination showed a normal gait and spinal contour.  Painful motion and tenderness were present, but spasm was absent.  ROM testing found forward thoracolumbar flexion of 60 degrees after repetitive motion (normal 90 degrees), and combined ROM of 125 degrees (normal 240 degrees).  Lower extremity muscle strength and sensation were normal.  X-ray showed stable post-operative and degenerative changes.  Electrodiagnostic studies showed no evidence of lumbar radiculopathy.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 20%, coded 5241 (spinal fusion).  The VA also rated the condition at 20% using the same code, citing limitation of motion as the rationale.  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 VA C&P examination.  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).  Finally, there was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  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 chronic low back pain condition.

BOARD FINDINGS:  In the matter of the low back 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 re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150217, 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-2015-00168.

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