RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX.	CASE:  PD-2015-00239
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20030402

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Helicopter Repairer, medically separated for “status post (s/p) C4-C6 laminoplasty for congenital cervical stenosis with persistent cervical myelopathy,” with a disability rating of 20%.

CI CONTENTION:  Contends the unfitting cervical condition including nerve damage, loss of motor skills, and loss of motion after surgery.  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 - 20030113	VARD - 20030403	
Condition	Code	Rating	Condition	Code	Rating	Exam	
S/P C4-C6 Laminoplasty for Congenital Cervical Stenosis with Persistent Cervical Myelopathy	5290	20%	S/P Cervical Spine Surgery w/Residual Degenerative Changes C4-5, C5-6, C6-7, and Degenerative Disc Changes C5-6	5003-5290	30%	20030129	
			Right Upper Extremity (RUE) Neuropathy … Cervical Spine Surgery	8510	20%	20030129	
			Left Upper Extremity (LUE) Neuropathy … Cervical Spine Surgery	8510	20%	20030129	
			Right Lower Extremity (RLE) Neuropathy … Cervical Spine Surgery	8520	20%	20030129	
			Left Lower Extremity (LLE) Neuropathy … Cervical Spine Surgery	8520	10%	20030129	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:

S/P C4-C6 Laminoplasty for Congenital Cervical Stenosis with Persistent Cervical Myelopathy.  The CI was left-hand dominant (major).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had neck and back pain beginning in October 1998 following a fall.  Neck and back pain increased and the CI was evaluated for bilateral arm and leg weakness and abnormal reflexes.  Diagnostic imaging confirmed cervical stenosis, degenerative changes and disk bulging that impressed the cervical cord and nerves.  The CI underwent laminoplasty of C4, C5, and C6 on 12 January 2002.  The MEB forwarded “cervical myelopathy” and “cervical kyphosis” for PEB adjudication.

At the MEB examination (recorded on DD Forms 2807, 2808, and 2697) dated 15 August 2002, 7 months prior to separation, the CI reported neck and lower back pain with “significant neurological damage.”  Physical examination showed tenderness to the cervical spine down to the lumbar area.  There was weakness (4/5) of the right arm and right leg.  Sensation and reflexes were intact in all extremities.

The MEB NARSUM examination on 21 October 2002, 5 months prior to separation, noted complaints of 7/10 neck pain with bilateral numbness in his upper extremities (right greater than left) and lower extremities with occasional paresthesias (pins and needles).  He noted trouble with fine movements of his upper extremities that worsened throughout the day.  He had generalized weakness of his left hand (5-/5) with more significant weakness in the right forearm, hand and fingers with difficulty picking up small objects like coins or buttons and problems with balancing or tripping frequently.  Physical examination showed a well healed surgical scan and the CI holding his head “with a slight forward lurch.”  There was normal upper extremity strength, slight numbness in the bilateral shoulder girdle and down into the hands and fingers (C6/C7 distribution) bilaterally, and a positive Hoffman’s sign (myelopathy/spinal cord compression reflex indicating upper motor neuron disease) bilaterally.  Upper extremity reflexes were otherwise normal.  There was slight weakness (5-/5) of the left leg lower leg (anterior tibialis and extensor hallucis longus), symmetric hyper reflexes (3+) and a positive (abnormal) Babinski bilaterally.  The CI failed tandem gait as he was unable to walk a straight line with heel-to-toe walking.  The CI could perform rapid alternating movements (no dysdiadokinesis).  The orthopedic surgeon stated that the CI “now has inability to perform fine tasks with his upper and lower extremities and unable to perform his duties.”

The physical therapy MEB range of motion (ROM) evaluation dated 11 December 2002 (4 months prior to separation) are charted below (NOTE:  The examiner did not list normal ROM values, so the current VASRD normal are noted for comparison only).

At the 29 January 2003 VA Compensation and Pension (C&P) evaluation, performed 3 months before separation, the CI reported feelings of tingling in the fingers and toes, with inability to “bend the toes in the right foot completely because they feel numb" with similar feeling affecting his left hand fingers; “he moves them but there is a feeling of awkwardness, especially when he attempts to do fine work.”  He related unpredictability of the muscles of the right and left legs in that they could become “involved in uncontrollable clonus agitation” which was likely to happen when he was standing or tired.

X-rays showed moderate to severe degenerative arthritis changes to C4 thru C7, retained hardware, and reversal of the cervical curve.  Physical examination showed limited and painful cervical ROM as charted below with examiner-specified normal ROM values.  Gait was normal.  The upper extremities showed normal strength with decreased sensation and abnormal (hyper) reflexes.  The lower extremities showed muscle atrophy of the right leg (34.5 cm versus 36.5 cm) with decreased strength of 3/5 compared to 5/5 (normal) on the left.  There was disturbed sensory perception and exaggeration (hyper) of the deep tendon reflexes.
The 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)	PT/MEB ~4 Mo. Pre-Sep	VA C&P ~3 Mo. Pre-Sep	
(Current VASRD normal)	Measured	Measured	Normal	
Flexion (45)	15	25	[65]	
Extension (45)	35	50	[50]	
R Lat Flex (45)	25	20	[40]	
L Lat Flex (45)	20	20	[40]	
R Rotation (80)	20	60	[80]	
L Rotation (80)	25	60	[80]	
Comment	Normal ROM values not provided	Examiner-specified normal ROMs	
§4.71a Rating	30% (PEB 20%)	30%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the cervical laminoplasty with persistent cervical myelopathy condition 20%, coded 5290 (spine, limitation of motion of, cervical), citing moderate decrease in cervical spine ROM with a 16% whole person impairment by AMA guide with normal upper extremity strength and 5-/5 lower extremity strength.  The PEB indicated that the disability existed prior to service (EPTS) and was not permanently aggravated by service, but was compensable IAW 10 USC 1207a.  The VA rated the cervical spine condition 30%, analogously coded 5003-5290 (degenerative arthritis with spine, limitation of motion of, cervical) based on the VA C&P examination 3 months before separation, citing 30% criteria of severe limitation of motion of the cervical spine (code 5290 criteria), or moderate limitation of motion with demonstrable deformity of a vertebral body from fracture (code 5290 with code 5285 criteria language).  The VA also rated each upper extremity and each lower extremity for neurologic residuals of the cervical condition, as indicated in the rating comparison chart above.

In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation which was the 2003 VASRD standards for the spine.  The applicable coding options for this case are excerpted below:

5285 Vertebra, fracture of, residuals:
With cord involvement, bedridden, or requiring long leg braces..............	100
Consider special monthly compensation; with lesser
involvements rate for limited motion, nerve paralysis.
Without cord involvement; abnormal mobility requiring neck 
brace (jury mast).........................................................................................	60
In other cases rate in accordance with definite limited motion
or muscle spasm, adding 10 percent for demonstrable deformity
of vertebral body.

5290 Spine, limitation of motion of, cervical:
Severe.........................................................................................................	30
Moderate....................................................................................................	20
Slight...........................................................................................................	10

5293 Intervertebral disc syndrome:
Evaluate intervertebral disc syndrome (preoperatively or
postoperatively) either on the total duration of
incapacitating episodes over the past 12 months or by
combining under Sec. 4.25 separate evaluations of its
chronic orthopedic and neurologic manifestations along with
evaluations for all other disabilities, whichever method
results in the higher evaluation.
With incapacitating episodes having a total duration of at
least six weeks during the past 12 months.................................................	60
With incapacitating episodes having a total duration of at
least four weeks but less than six weeks during the past 12
months........................................................................................................	40
With incapacitating episodes having a total duration of at 
least two weeks but less than four weeks during the past 12
months........................................................................................................	20
With incapacitating episodes having a total duration of at
least one week but less than two weeks during the past 12
months.......................................................................................................	10

Note (1): For purposes of evaluations under 5293, an
incapacitating episode is a period of acute signs and
symptoms due to intervertebral disc syndrome that requires
bed rest prescribed by a physician and treatment by a
physician. ``Chronic orthopedic and neurologic
manifestations'' means orthopedic and neurologic signs and
symptoms resulting from intervertebral disc syndrome that are
present constantly, or nearly so

Note (2): When evaluating on the basis of chronic
manifestations, evaluate orthopedic disabilities using
evaluation criteria for the most appropriate orthopedic
diagnostic code or codes. Evaluate neurologic disabilities
separately using evaluation criteria for the most appropriate
neurologic diagnostic code or codes

The Board agreed that a 30% rating, was justified for severe limitation of cervical flexion reported on the physical therapy MEB and VA examinations.  Although the CI had intervertebral disc disease, there were no incapacitating episodes requiring physician-prescribed bed rest to warrant any higher rating under code 5293.

The Board next considered if any neuropathy rose to the level of being unfitting and ratable.  The MEB diagnoses were; “cervical kyphosis” an orthopedic condition deliberated above, and “cervical myelopathy” which is a neurologic condition (upper motor neuron).  The PEB disability description included persistent cervical myelopathy addressing upper and lower extremity strength.  This was considered a presumptive assessment that no extremity neuropathy was considered separately unfitting.  The Board’s main charge was to assess the fairness of the PEB’s implied determination that the upper and lower extremity neuropathies were not unfitting conditions.  

The cervical myelopathy condition was profiled, implicated in the commander’s statement and judged to fail retention standards.  Profile dated July 2002 listed “weakness, and paresthesias (abnormal sensations)” and included a U3L3 designation and multiple duty restrictions.  The commander’s statement, dated 5 August 2002, indicated the CI’s “loss of motor control with clumsiness greatly reduces his effectiveness” and prevented him from effectively conducting his duties.  The MEB NARSUM physician indicated that the CI’s “inability to perform fine tasks with his upper and lower extremities” and made the CI unable to perform his duties.

The CI had persistent cervical myelopathy affecting both the arms and the legs that were either unresolved, or worsened, after surgery.  There were symptoms of slight weakness, abnormal reflexes and gait/balance disturbance documented in the treatment records that interfered with his job.  The Board considered each extremity separately as well as the probative value of the disparate examinations in evidence.

Regarding the upper extremities:  Both upper extremities had some disability due to myelopathy.  The duty impairing aspect of the upper extremity dysfunction was decreased sensory function and fine motor control rather than weakness.  The Board adjudged that only the dominant (major) left hand disability due to myelopathy reached the preponderance of the evidence for being separately unfitting, with less convincing evidence for the non-dominant (minor) upper extremity.  The left upper extremity myelopathy is appropriately coded analogous to 8510 (upper radicular group (fifth and sixth cervical) and rated 20% (mild) incomplete paralysis.

Regarding the lower extremities:  Although both lower extremities had some disability due to myelopathy, the duty impairing aspect of the lower extremity dysfunction was decreased fine motor control (clumsiness) and uncertain movement (clonus/leg movements with fatigue), and weakness that interfered with prolonged standing or running.  The VA examination documented muscle weakness with atrophy only in the right leg, with sensory and reflex abnormalities in both legs.  The Board adjudged that only the right leg disability due to myelopathy reached the preponderance of the evidence for being separately unfitting.  The right lower extremity myelopathy is appropriately coded analogous to 8520 (upper radicular group (fifth and sixth cervical)) and rated 20% (mild) incomplete paralysis.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the cervical laminoplasty with persistent cervical myelopathy condition, coded 5290; as well as an unfit finding and the addition of a disability rating of 20%, coded 8799-8510, for the left (major) upper extremity myelopathy, and an unfit finding and a disability rating of 20%, coded 8799-8520, for the right lower extremity myelopathy, both IAW VASRD §4.124a.

BOARD FINDINGS:  In the matter of the cervical laminoplasty with persistent cervical myelopathy condition, the Board unanimously recommends a disability rating of 30%, coded 5290 IAW VASRD §4.71a; plus an unfit finding and a disability rating of 20%, coded 8799-8510, for the left (major) upper extremity myelopathy, and an unfit finding and a disability rating of 20%, coded 8799-8520, for the right lower extremity myelopathy, both IAW VASRD §4.124a.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
S/P C4-C6 Laminoplasty for Congenital Cervical Stenosis with Persistent Cervical Myelopathy	5290	30%	
Left Upper Extremity Myelopathy S/P Cervical Spine Stenosis and Surgery	8799-8510	20%	
Right Lower Extremity Myelopathy S/P Cervical Spine Stenosis and Surgery	8799-8520	20%	
COMBINED	60%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150401, 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

06 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170000660 (PD201500239)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 60% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 60% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:

Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA