RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00330
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090515

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Still Photography Craftsman, medically separated for “low back pain status-post discectomy,” with a disability rating of 10%.  

CI CONTENTION:  The CI makes no contentions.  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 - 20090413	VARD – None	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain Status-Post Discectomy	5243	10%	No VA Examination in Evidence	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Low Back Pain (LBP) Status-Post (S/P) Discectomy.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent back surgery for diskectomy and decompression in April 2008.  Following the surgery the CI initially improved but developed recurrent back pain with radiation to the right hip.  Radiographic studies (X-ray) on 21 October 2008 showed minimal scoliosis, mild narrowing of the L5-S1 disc space and no evidence of lumbar spine instability.  A magnetic resonance imaging (MRI) study done on 21 October 2008 showed scar tissue around the exiting S1 nerve root without nerve compression or a new disc herniation.  The MEB forwarded “S/P lumbar spine diskectomy” for PEB adjudication.  At the physical therapy (PT) range of motion (ROM) examination for the MEB performed on 9 December 2008, approximately 5 months prior to separation, the CI reported low back and right hip pain.  The physical examination showed a non-antalgic gait, muscle strength was 5/5 and straight leg testing to elicit radicular symptoms was negative.  There was tenderness to palpation over the bilateral sacroiliac joints.  Back ROM was flexion of 90 degrees (90 degrees normal) and combined ROM was 230 degrees (normal 240 degrees).  

The MEB NARSUM examination on 2 January 2009, approximately 4 months prior to separation, noted complaints of mild to moderate LBP with running and other physical activities, which included lifting greater than 20 pounds.  There were functional limitations of an inability to run, perform push-ups, sit-ups or push/pull/lift greater than 20 pounds or run 100 yards with a 40 pound pack.  The examiner used the PT ROMs done in December 2008 and additionally noted mild pain with full flexion.  The CI did not file a VA claim, therefore there was no VA Compensation and Pension examination in evidence and no VA Rating Decision in record.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, coded 5243 (Intervertebral disc syndrome).  There is no record of the VA rating the LBP condition.  The Board agreed that a 10% rating, but no higher, was justified for sacroiliac tenderness and limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the PT MEB ROM evaluation.  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 documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  The Board’s rating recommendation is for the low back pain and sacroiliac dysfunction together (tender SI joints at PT MEB ROM evaluation) IAW VASRD §4.66 (sacroiliac joint) which stipulates “The lumbosacral and sacroiliac joints should be considered as one anatomical segment for rating purposes.”  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 LBP, S/P diskectomy condition.  

BOARD FINDINGS:  In the matter of the LBP, S/P diskectomy 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 20150526, 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-2015-00330.

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