RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00319
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060519

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O3, clinical nurse, medically separated for “neck pain, status post (S/P) C5-6 anterior decompression and fusion,” with a disability rating of 10%.  

CI CONTENTION:  The CI contends she was given a higher rating for her condition by the VA as well as rating for additional conditions, migraines, radiculopathy right and left upper extremity and lumbar spine.  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 - Dated 20060315	VA - 20070403	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Neck Pain S/P C5-6 Anterior Decompression and Fusion	5241	10%	Traumatic Arthritis and Disc Disease of the Cervical Spine	5010-5242	20%	20061228	
			Scar, Neck S/P Spinal Fusion C5-6	7800	0%		
			Radiculopathy, Left Upper Extremity	8515	10%		
			Radiculopathy, Right Upper Extremity	8515	10%		
Low Back Pain (LBP) with DDD	Cat II 	Degenerative Disc Disease, Lumbar Spine	5242	20%		
		Sciatica, Left Lower Extremity	8520	NSC		
Migraine Headaches		Migraines	8100	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Neck Pain S/P C5-6 Anterior Decompression and Fusion.  The CI was right-handed.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck pain condition began in December 2001.  There was no specific trauma except for an incident where a walk-around oxygen bottle fell and struck her head.  The CI noted neck pain with upper extremity weakness and pain became severe.  Diagnostic imaging showed multi-level degenerative changes with degenerative disc disease (DDD) with C5-6 canal stenosis and cord myelopathy changes.  The CI underwent an anterior cervical diskectomy and fusion at C5-6, with allograft bone and titanium plate/screws surgery in February 2005.  

At the time of the neurosurgery clinic appointment on 10 November 2005, the CI reported a 2-year history of numbness and burning to her bilateral thumbs and index fingers.  Diagnostic imaging (magnetic resonance imaging (MRI) and X-rays) done in August 2005 showed the cervical graft in place with some fusion and with myelopathy at C6.  The physical examination showed decreased sensation in the left thumb consistent with a C6 injury with normal strength, reflexes and pincer strength.  The examiner diagnosed residual cord myelopathy, indicated that there was no surgical option, and started neuroactive medication (Gabapentin).  Despite treatment, the cervical spine 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 NARSUM examination on 21 December 2005, 5 months prior to separation (10 months after surgery), noted CI complaints of constant neck pain rated at 6-7/10 with flares to 8-10/10.  She reported persistent left upper extremity weakness and chronic bilateral numbness and tingling in her thumbs, index and middle fingers which interfered with dexterity and fine motor tasks “like starting an IV.”  She noted that when she bent her neck in a lateral position, the numbness and tingling in her left upper extremity increased.  She could not tolerate wear of a helmet, lifting over 10 pounds, or doing any significant activities or prolonged sitting/standing.  She required narcotic pain medication regularly.  Diagnostic imaging indicated cervical fusion had “incorporated proximately but not necessarily distally.”  The physical examination showed a well healed cervical scar with decreased range of motion (ROM) of her neck limited by stiffness and pain (see chart).  “She had a normal upper and lower extremity neuro examination except for some subjective digit and wrist extension weakness on the left side.”  There was objective decreased motor strength on the left side with left grip 63 pounds versus 80 pounds on the right and pinch test of 15 pounds versus 19 pounds on the right.  The diagnosis was persistent neck pain, status post anterior cervical decompression and fusion, with cervical myelopathy, degenerative disk disease, and cervical spondylosis.  

The commander’s statement dated 23 January 2006 noted that the CI had constant neck pain and numbness which limited her deployability although she continued to work close to full capacity.  The commander stated “this has not compromised her performance as a nurse or her ability to function in her capacity as an Air Force officer” and recommended “return to duty.”  

At the VA Compensation and Pension (C&P) examination in December 2006, performed approximately 7 months after separation, the CI reported her neck pain had gotten progressively worse along with numbness and tingling with occasional discomfort that radiated down the lateral aspect of the her upper arm and out to the thumb, index and middle finger on her left hand and mainly on the tip of her index finger on the right hand.  She noted she would occasionally drop things with her left hand and had difficulty typing with her left hand.  She rated the chronic neck pain at 7/20 with flares if she tried to rotate her head too far left and fatigue or stress increased the pain to 10/10.  Diagnostic imaging done in August 2006 showed stability of the implanted hardware and progression of DDD with new development of kyphosis and with severe left neural foraminal narrowing at the C4-C5 level and mild left narrowing at the C2-C3 and C3-C4 levels; there were indications of injury/demyelination at C6.  The physical examination showed decreased sensation of the left thumb and index finger (dullness or frequent misses of touching with a 5 gm fiber or the light touch of a cotton tipped wisp on the left thumb and index finger).  There was normal upper extremity strength and coordination.  The neck physical examination findings are summarized in the chart below.  

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)	Ortho/MEB ~5 Mos. Pre-Sep	VA C&P ~7 Mos. Post-Sep	
Flex (45 Normal)	35	45	
Combined (340)	280	170	
Comment:  Surgery ~15 Mos. Pre-Sep	Painful motion	Painful motion	
§4.71a Rating	10%	20%	

The Board directed attention to its rating recommendation based on the above evidence.  The Formal PEB assigned a 10% rating under the 5241 code (spinal fusion).  The VA assigned a 20% rating coded 5010-5242 (arthritis, due to trauma - degenerative arthritis of the spine) based on the VA C&P examination approximately 7 months after separation, citing combined ROM not greater than 170 degrees.  

The Board considered the probative value of the Service and VA examination and adjudged that the Service examination had the highest probative value for rating at separation, as the VA examination was further from separation and records indicated progressive worsening of the CI’s condition.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 40 degrees) reported on the NARSUM.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI had a cervical herniated disc with radicular symptoms treated with surgery, and there were chronic symptoms of radiating pain (left worse than right) with left hand weakness and sensory deficit.  Diagnostic imaging supported some level of radicular nerve myelopathy, irritation or involvement; however, the presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation-specific activities.  There was clear evidence that the commander and the Formal PEB did not find sufficient evidence in this case that motor weakness or sensory deficits significantly impaired duty performance.  The Board concluded an additional disability rating was not justified on this basis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB adjudication for the neck condition.  

Contended PEB Conditions:  Low Back Pain (LBP) with DDD, Migraine Headaches.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The LBP condition was judged to fail retention standards and was possibly included in the U4 profile restrictions, while the migraine headache condition was not judged to fail retention standards and not indicated in any profile restriction.  The commander’s statement mentioned the LBP and not the headache condition, but also indicated that the CI’s medical conditions and profile limitations had not compromised her performance.  The Formal PEB also considered both the LBP and headache conditions and affirmed that they were not unfitting.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the Formal PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the Neck Pain S/P C5-6 Anterior Decompression and Fusion condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended low back pain and migraine headache conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20150219, 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-2015-00319.

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