RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00170
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20020903

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Air Surveillance Technician, medically separated for “cervical fusion C5-6 with residual radiculopathy,” with a disability rating of 10%.  

CI CONTENTION:  He was rated too low, his condition continues to worsen and impact his daily life, and his shoulder condition was not included in his separation evaluation.  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 - 20020618	VARD - 20020906	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Fusion C5-6 with Residual Radiculopathy	5290	10%	Residuals of Cervical Fusion with Degenerative Disc Disease	5290-5010	10%	20020801	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Cervical Fusion C5-6 with Residual Radiculopathy.  The CI was left-handed.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s cervical fusion C5-6 with residual (right arm) radiculopathy condition began in September 2000 after experiencing chronic neck pain that resulted from a collision playing softball in August 1998.  Diagnostic imaging studies (MRI) 12 October 2000 and discogram in July 2001 showed bulging intervertebral discs at C5-6 with impingement on the C5-6 spinal nerve root.  The CI underwent surgical neck fusion at C5-6 in August 2001 (anterior discectomy and osteophytectomy allograft fusion and plating).  Diagnostic imaging studies (X-ray) 27 November 2001 revealed postoperative surgical discectomy and fusion changes at C5-6 with stable alignment.  (The CI also injured his right shoulder rotator cuff at the same time as his cervical injury and underwent right shoulder surgery [arthroscopy and acromioplasty] in April 2001, with resolution of his shoulder pain.)  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “cervical neck fusion C5-6 with residual radiculopathy,” for PEB adjudication.  

The range of motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Cervical ROM
(Degrees; Current Normal)	MEB ~3 Mos. Pre-Sep	VA ~1 Mos. Pre-Sep	
		Normal	Measured	
Flexion (45)	90	65	50	
Extension (45)	45	50	45	
R Lat Flex (45)	60	40	40	
L Lat Flex (45)	70	40	40	
R Rotation (80)	45	80	60	
L Rotation (80)	90	80	80	
Comments:  Surgery ~12 Mos. Pre-Sep	Limited rotation	Painful motion; tenderness; normal gait	
§4.71a Rating	10%	10%	

During the MEB examination dated 31 May 2002, 3 months prior to separation, the CI reported he had improved status post surgery, but reported increased neck and brachial (right arm) pain when running or heavy lifting.  Physical examination showed normal strength (5/5) and normal reflexes of the bilateral upper extremities.  There was decreased sensation to pinprick on the right 4th and 5th fingers (ring-finger and pinky).  The ROM was mildly limited as recorded in the chart above.  The CI’s letter to the PEB (11 June 2002) noted return of symptoms following surgery, “loss of sensation in the fingertips and inner arm and lower arm becoming constant and seems to increase with an increase in physical activity.  … Limiting my activity can lessen severe pain or loss of feeling.”  

At the 1 August 2002 VA Compensation and Pension (C&P) evaluation, performed 1 month before separation, the CI reported constant neck pain and limited ROM.  The pain seemed to travel to other parts of his body, including the right arm and finger tips.  The CI could perform normal daily activities, but the pain was aggravated by climbing stairs.  The pain was relieved by bed rest and treatment by a physician about every 3 months.  Physical examination showed normal posture and gait.  There was no muscle spasms or weakness of the neck.  Reflexes were normal.  There was decreased sensation in the right upper extremity in the C5 distribution and decreased strength in the right upper extremity, with strength 4/5 (normal 5/5).  There were no signs of radiculopathy on testing.  There was tenderness to palpation over the C5-6 area.  The ROM was limited by pain as recorded in the chart above.  X-rays showed degenerative arthritis; status post cervical fusion, C5-6.  

The Board directed attention to its rating recommendation based on the above evidence.  In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation.  The Board noted that the 2002 Veteran Administration Schedule for Rating Disabilities (VASRD) standards for the spine, which were in effect at the time of separation, were changed effective 23 September 2002 for code 5293 (intervertebral disc syndrome) and changed to the current §4.71a rating standards effective 26 September 2003.  The Board must correlate the above clinical data with the 2002 rating schedule; applicable diagnostic codes include: 5290 (limitation of cervical spine motion); and 5293 (intervertebral disc syndrome); and [analogously to] 5295 (lumbosacral strain).  The 2002 criteria relevant for consideration in the Board’s recommendation are cited in context below.  
The PEB rated the cervical fusion C5-6 with residual radiculopathy condition 10% under the analogous 5290 code (spine, limitation of motion of, cervical).  The VA also assigned a 10% rating using the analogous 5290-5010 code (spine, limitation of motion of, cervical – traumatic arthritis) for painful limitation of motion.  

The 5290 criteria are slight (10%), moderate (20%) and severe (30%).  The Board agreed that there was not sufficient limitation of cervical spine motion to warrant any rating greater than the 10% awarded by the PEB.  Rating analogous to 5295 would be no higher than 10% for characteristic pain on motion.  The Board also considered if alternative rating under code 5293 (intervertebral disc syndrome), for symptoms compatible with radiculopathy, was greater than the 10% criteria of “mild.”  The CI reported intermittent numbness to his right arm and hand with all exams showing decreased sensation of the right 4th and 5th fingers with normal upper extremity reflexes.  The service exams and STRs did not show any right arm weakness; however, the VA exam 1 month prior to separation indicated right arm weakness (4/5) without specifying any joint, muscle action, or nerve distribution of the weakness.  

The Board agreed that the Service examinations and STR had the highest probative value for rating at separation.  The Board majority agreed that there was sufficient evidence of “moderate; recurring attacks” to support the next higher (20%) rating, but not the 30% “Severe; recurring attacks, with intermittent relief” criteria.  The alternative of a 10% 5290 (cervical motion) rating plus a 10% 8616 (radiculopathy) for a combined 20% rating was deliberated.  The Board majority considered alternative rating of the CI’s radiculopathy, but adjudged that rating under code 5293 for symptoms compatible with neuropathy was predominant as the only fixed neurologic deficit was sensation of the right (non-dominant/minor) 4th and 5th fingers.  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 cervical fusion C5-6 with residual radiculopathy condition, coded 5290-5293.  

BOARD FINDINGS:  In the matter of the cervical fusion C5-6 with residual radiculopathy condition, the Board majority recommends a disability rating of 20%, coded 5290-5293 IAW VASRD §4.71a.  The single voter for dissent recommended modification of the disability rating (with alternative coding) and did not elect to submit a minority opinion.  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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Cervical Fusion C5-6 with Residual Radiculopathy	5290-5293	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150218, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

PDBR PD-2015-00170

MEMORANDUM FOR THE CHIEF OF STAFF

	Having received and considered the recommendation of the Physical Disability Board of Review and under the authority of Title 10, United States Code, Section 1554a (122 Stat. 466) and Title 10, United States Code, Section 1552 (70A Stat. 116) it is directed that:

	The pertinent military records of the Department of the Air Force relating to XXXXXXXXXXXXXXXXXXXXX, be corrected to show that the diagnosis in his finding of unfitness for Cervical Fusion C5-6 with Residual Radiculopathy, VASRD code 5290-5293, was rated at 20% rather than 10%.

XXXXXXXXXXXXXXXXXXXXX
Principal Deputy Assistant Secretary 
(Manpower and Reserve Affairs