RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00282
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20021028

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E7, Signal Voice Interceptor, medically separated for “low back pain” with a disability rating of 10%.  

CI CONTENTION:  The CI contends his sciatica was not considered and believes the sciatica is a separate condition from his back condition.  

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 – 20020724	VARD - 20030320	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain Residual	5299-5295	10%	Residuals, L5-S1 Laminectomy with Degenerative Joint Disease	5295	10%	20030119	
			Scar, Lumbar L5-S1	7804	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Low Back Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in May 1997.  The CI initially complained of right hip pain and was diagnosed with sciatica.  The CI had with a history of right S1 radiculopathy (nerve root irritation or injury) which was refractory to conservative therapy.  Magnetic resonance imaging (MRI) demonstrated a right L5-S1 herniated nucleus pulposus (gelatinous disc core) with compression of the nerve root.  The CI was referred to neurosurgery and on 26 March 1998 underwent a facetectomy (excision of facet joint [s]), laminotomy (partial excision of lamina), and discectomy (partial/complete excision of intervertebral disc).  He enjoyed symptom improvement until May 2001 when his pain began to increase.  An 11 June 2001 lumbar spine MRI showed postsurgical changes, a small recurrent or residual disc protrusion at L5-S1, and transitional anatomy (congenital variation of lumbosacral joint involving lowermost lumbar vertebra or uppermost sacral segment) of the S1 vertebral segment.  In July 2001, the CI experienced a bike accident which worsened the back pain.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “low back pain S/P discectomy” for PEB adjudication.  

At the MEB examination on 14 May 2002, 5 months prior to separation, the CI complained of persistent back and leg pain.  There was associated aching, shooting pain involving the whole back and chest and radiation into the right hip, knee, ankle, and calf.  Symptoms were exacerbated by prolonged sitting, standing (5-10 min), walking, running, lifting, and physical training and minimally relieved by laying on the floor and stretching. The back examination revealed a lower back scar, mild L3-L5 tenderness, and decreased range of motion (ROM).  The straight leg raise (SLR) test (assesses for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) was negative.  

The MEB NARSUM examination on 27 June 2002, 4 months before separation, recounted the history and interventions.  The CI complained of worsening back and right leg pain.  He did not experience significant improvement following surgery with activity modification, physical therapy (PT), epidural steroid injections, trigger point injections, and medications and no surgery was indicated.  The focused examination documented “Back:  Decreased ROM, mild TTP midline L3-5.” The examiner recounted the findings of the X-rays, MRIs, and consultations (neurosurgery, pain management, and PT).  The diagnosis listed chronic lower back pain with radiculopathy, status post L5-S1 discectomy and laminectomy.  At a 30 July 2002 physical medicine and rehabilitation (PM&R) encounter, the CI complained of right sided low back pain with radiation up the dorsal paraspinal muscles and down the right lower extremity (LE).  He reported associated right LE paresthesias involving mostly the lateral foot.  The physical examination documented the CI could flex to 3.0 cm from the floor (~80-90 degrees).  Lumbar spine range of motion (ROM) was extension of 50% and bilateral lateral flexion of 50%.  Thoracic spine ROM was bilateral rotation of 25%. The electro diagnostic (EDX) studies on 4 August 2002, 2 months prior to separation, were normal and showed no evidence of bilateral lumbar-sacral spine radiculopathy.  

At the 19 February 2003 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI complained of shooting 4-6/10 pain that radiated from the lumbosacral spine area down the right buttock to the medial side of the foot.  He reported associated low back spasms but denied leg weakness, unsteadiness, falls, and bowel or bladder problems.  Symptoms were exacerbated by prolonged standing, prolonged sitting, driving, lifting, and pushing and relieved with standing, stretching, walking, and medications (Motrin, Flexeril, and Vicodin).  The physical examination documented a gait without any limp.  The back examination revealed a normal curvature and no atrophy.  There was L5 muscle spasm and a scar in the L5 area with surrounding tenderness. Lumbar spine ROM was flexion of 80 and extension of 15 degrees.  Strength and deep tendon reflexes (DTRs) were normal and there was altered sensation of the right leg below the knee and the top of the foot.  The lumbosacral spine X-ray showed a normal lumbar spine with a transitional vertebra at the lumbosacral junction.  The diagnosis listed back pain from degenerative joint disease, spinal disease, status post laminectomy, and sacralization (congenital fusion of L5 vertebra to sacrum) of lumbar spine.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5295 code (lumbosacral strain) citing low back pain residual following L5-S1 discectomy, residual pain into right hip and posterior leg, initial significant improvement with recurrence following cycling accident.  MRI suggested recurrence of L5-S1 disc protrusion, further surgery not advised, and rated for lumbosacral strain with characteristic pain on motion.  The VA assigned a 10% rating under the 5295 code (lumbosacral strain) based on the VA C&P examination 4 months after separation, citing chronic low back pain, residuals  of L5-S1 laminectomy, degenerative joint disease, radiculopathy syndrome, ROM, lumbar spine muscle spasm, degenerative disc disease by X-rays, and rated for characteristic painful or limited motion.  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 VASRD standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards in 2004.  The Board must correlate the above clinical data with the 2002 rating schedule and applicable diagnostic codes.  There was no vertebral fracture (5285), complete spine ankylosis (5286), lumbar spine ankylosis (5289), or sacro-iliac injury/weakness (5294) for consideration under the respective codes.  While the CI had recurrence of a small L5-S1 disc protrusion with intermittent radicular symptoms, the EDX studies were normal and the proximate examinations documented normal strength, DTRs, and gait.  There was no neuropathy, characteristic pain, muscle spasm, absent DTR, neurological findings appropriate to disc site, or recurring attacks for consideration under intervertebral disc syndrome (5293).  The sensory disturbances did not affect his job.  The critical decision is whether or not there was a significant motor weakness or sensory impairment which would impact military occupation specific activities.  The Board agreed there was lumbar spine limitation of motion and characteristic pain on motion for consideration under the limitation of lumbar spine motion (5292) and lumbosacral strain (5295) codes respectively.  Board members agreed symptoms were consistent with the characteristic pain on motion (10%) under lumbosacral strain (5295).  Board members agreed that the ROM values more closely approximated the slight (10%) than the moderate (20%) rating under lumbar spine limitation of motion (5292).  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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 back condition.  

BOARD FINDINGS:  In the matter of the low back 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 20150425, 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 
XXXXXXXXXXXXXXXXXX, AR20170000921 (PD201500282)

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