RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00255
BRANCH OF SERVICE:  Army
DATE PLACED ON TDRL:  20030318
DATE REMOVED FROM TDRL:  20080327

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Armor Crewmember, medically separated from the Temporary Disability Retired List (TDRL) for “seizure disorder”  with a disability rating of 20%.

CI CONTENTION:  The CI contends his rating should have been higher. 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 – 20030318/20080226	VARD -20030908	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Recurrent Subdural Hematoma (Placement); Seizure Disorder (Removal)	5296; 8910	50%	20%	Post-Surgical Skull Defect with Removed Bone Flap …Post Subdural and Epidural Hematoma	5296	50%	--	
				Status Post Subdural and Epidural Hematoma	8009	10%	--	
Combined Rating:  50% → 20%	Combined Rating Of All Va Conditions:  60%	

ANALYSIS SUMMARY:  

Recurrent Subdural Hematoma.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s brain condition began in November 2002 after he struck his head on concrete during combat training.  The CI subsequently developed headaches and evaluation revealed a subdural hematoma which was surgically evacuated.  No postoperative neurological deficits were present.  In December 2002, the headaches returned and a second surgical procedure was carried out consisting of a craniectomy (removing a portion of the skull) with removal of a bone flap, drainage of an epidural hematoma, securing a cerebral fluid leak with lumbar drains, and repair of the middle meningeal artery.  No neurologic deficits or seizures occurred at that time.  The CI’s skull defect was reported in March 2003 to be 12 square inches as measured from the lateral tomogram of a CT scan.  Despite treatment, the brain condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “status post subdural hematoma evacuation with bone flap removal” for PEB adjudication and the CI was placed on TDRL.

At the first TDRL review in November 2006, the CI’s condition was unchanged and the rating remained the same.  On the final TDRL review in December 2007, it was noted that the CI underwent a left cranioplasty (to repair the skull defect) with implant placement.  His postoperative recovery was complicated by an infection and two posttraumatic seizures the latter of which was in January 2007 that was well controlled with Keppra (levetiracetam, a seizure preventative medication).  A note in May 2007 indicated the CI was suspected to have major depression, which may have reflected the CI’s brain injury.  Subsequent neurologic and neurosurgical follow-ups noted headaches associated with dizziness, which improved with time and were treated with Tylenol (acetaminophen, a pain reliever).  However, he called in late to work three times a week when he had the headaches. He reported the depression was well controlled with Celexa (citalopram, an antidepressant medication).  The CI was noted in an email from a neurosurgeon dated 6 February 2008 that “he may wear a Kevlar or other headgear.”  In January 2008 neuropsychological testing revealed a range of intact cognitive abilities although cognitive performance on the assessment was not fully conclusive as measures of test validity and/or patient response consistency were determined to be not optimal.  Psychologically, the CI may have had depression with somatic concerns secondary to the seizure disorder.  His clinical picture was also reportedly complicated by marital issues.  His report of difficulties with concentration and short-term memory may have been due to multiple factors including the seizure condition, being status post subdural hematoma, affective factors, medication influences, and inadequate sleep quality.  The neuropsychologist postulated that the cognitive issues could not be definitely delineated, the possible cognitive deficits and psychological distress with depression suggested the CI was not a candidate for return to full-time duty.   His Global Assessment of Functioning was 60 (moderate symptoms).  Follow-up recommendations were made for neuropsychological testing, stabilization of seizure control and headaches, use of an organizer/planner, sleep hygiene techniques and adjunctive pain relief.

At the MEB examination in February 2003, 1 month prior to separation, the CI reported a brain injury and subsequent surgeries.  Physical examination showed an open partial wound of the scalp over which the CI wore a protective helmet. 

At the 14 August 2003 VA Compensation and Pension (C&P) evaluation, performed 5 months after separation, the CI reported occasional left-sided headaches which occurred with activity on a scale of 8/10 (10 being the worst pain).  He clearly had trouble remembering and was not as competent as he was before.  Physical examination revealed the CI’s head, eyes, ears, nose and throat were unremarkable.  Neurological evaluation demonstrated normal sensory, motor, coordination, deep tendon reflexes, cranial nerves, and gait.  There was an obvious defect in his left parietal area which was approximately 8 cm in diameter, while X-rays of the skull revealed an 11 x 8 cm generally round, left frontoparietal craniectomy defect with one surgical clip present in the area and no evidence of increased intracranial pressure.  The impression was a large left frontoparietal craniectomy defect.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the recurrent subdural hematoma condition 50%, coded 5296 (Skull, loss of part of, both inner and outer tables:  Without brain hernia: Area larger than size of a 50-cent piece or 1.140 in2 (7.355 cm2)), citing recurrent subdural hematoma following head injury complicated by infection and requiring removal of 12 square inches of calvarium, with subsequent large skull defect for TDRL placement.  The VA rated the recurrent subdural hematoma condition 50% coded 5296 (Skull, loss of part of, both inner and outer tables:  Without brain hernia: Area larger than size of a 50-cent piece or 1.140 in2 (7.355 cm2)), based on the VA C&P examination 5 months after separation, citing post-surgical skull defect with removed bone associated with status post subdural and epidural hematoma.  The VA also assigned a 10% rating using code 8009 (Brain, vessels, hemorrhage from: Rate residuals, thereafter, minimum), citing status post subdural and epidural hematomas.  Board members considered the CI’s rating at the time of TDRL placement and there was no higher rating option using code 5296 in the absence of brain herniation.  However, Board members noted the VA used the 8009 code, which directs rating in this case to code 8008 (Brain vessels, thrombosis of) for a period of 6 months.  The CI underwent a second surgery to evacuate an epidural hematoma on 12 December 2002 and TDRL placement was on 18 March 2003.  Therefore, Board members agreed it’s appropriate to consider a 100% rating for initial placement for 6 months and at least 50% thereafter through the TDRL period.  

The PEB rated the recurrent subdural hematoma condition 20%, coded 8910 (Epilepsy, grand mal.  At least one major seizure in the last 2 years; or at least two minor seizures in the last 6 months), citing recurrent subdural hematoma following head injury complicated by infection and requiring removal of 12 square inches of calvarium, with subsequent large skull defect seizure disorder for TDRL removal.  However, the CI had two seizures, but more than a year prior to separation; therefore a higher rating using code 8910 cannot be achieved.  Members also considered use of code 8045 (residuals of traumatic brain injury (TBI)) as a possible route to a higher rating, but of the evaluation of cognitive impairment and other residuals of TBI not otherwise classified, the CI level of impairment was more consistent with a complaint of mild loss of memory, which was not confirmed objectively on testing, albeit the testing was not fully conclusive.  Additionally, while the CI had headaches they did not interfere with work or activities of daily living.  Therefore, a 10% rating using code 8045 was the maximum rating achievable, which offers no benefit to the CI.  Most importantly, however, the CI still had a defect in the skull, although it was covered with an artificial implant.  The neurosurgeon felt the CI could wear a Kevlar or other head covering, but did not specifically address a combat vehicle crewman’s CVC helmet.  However, the preponderance of evidence suggested the skull defect is unfitting based on the CI’s MOS as an armored crewmember where work in a confined space with close quarters or in a turret for long periods of time along with rumbling, vibration, jarring, loud sounds and vehicle noise, and shock wave exposures secondary to weapon discharges along with heavy lifting can be problematic with the prolonged use of Kevlar or a CVC helmet as well as potentially detrimental to the implant and surrounding structures including the CI’s brain.  Therefore, on TDRL removal based on the CI’s overall condition of skull defect, history of evacuations of subdural and epidural hematomas, and cognitive changes would be appropriately rated 50% using 5296 code, since the VASRD defines the code as “skull, loss of part of both inner and outer tables without brain hernia” and does not subtract from any of the rating options based on size for an implant.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 100% for the recurrent subdural hematoma condition, coded 8008 for TDRL initial placement for 6 months and a 50% rating using code 5296 for the remainder of the TDRL period.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% using code 8910 for the seizure disorder and a 50% rating using code 5296 for the skull defect s/p subdural epidural hematomas for TDRL removal.  

BOARD FINDINGS:  In the matter of the recurrent subdural hematoma condition, the Board unanimously recommends a disability rating of 100%, coded 8008 IAW VASRD §4.124a for the first 6 months of TDRL placement and a disability rating of 50%, coded 5296 IAW VASRD §4.71a for the remainder of the TDRL period.  In the matter of the seizure disorder condition, the Board unanimously recommends a disability of rating of 20%, coded 8910 IAW VASRD §4.124a and in the matter of the recurrent subdural hematoma condition, the Board unanimously recommends a disability rating of 50%, coded 5296 IAW VASRD §4.71a for TDRL removal.  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	RATING	
		TDRL (Initial Placement-6 months)	TDRL (Stability Placement)	PERMANENT	
Recurrent Subdural Hematoma 	8008	100%			
Recurrent Subdural Hematoma	5296		50%		
Seizure Disorder	8910			20%	
Recurrent Subdural Hematoma 	5296			50%	
RATING	100%	50%	60%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150407, 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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20170003454 (PD201500255)

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,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA