RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX.	CASE:  PD-2015-00410
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030127

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Cargo Specialist, medically separated for “back pain with thoracolumbar scoliosis” with a disability rating of 0%.

CI CONTENTION:  The CI contends that his service-aggravated back condition should have been rated higher than 0%.  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 - 20021127	VARD - 20030909	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Back Pain with Thoracolumbar Scoliosis	5299-5295	0%	Mild Scoliosis of the Thoracic Spine with a Mild Curvature of the Lumbar Spine to the Left	5295	NSC	20030311	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Low Back Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the low back condition began approximately 2 years prior to MEB referral.  An 11 May 2000 lumbar spine X-ray showed an abnormal curvature of the spine.  In the 25 January 2002 NARSUM, 12months before separation, the CI reported of onset of progressively worsening back pain beginning in early 2000.  He complained of constant right-sided back pain at the thoracolumbar junction which was exacerbated by physical activity.  He did not experience significant improvement with physical therapy (PT) and medications (nonsteroidal anti-inflammatory drugs [NSAIDs] and Ultram).  The back examination revealed right thoracolumbar scoliosis (abnormal lateral spine curvature).  Thoracic spine computed tomography (CT) revealed a scoliotic curve and some degenerative changes.  Thoracic and lumbar spine magnetic resonance imaging (MRI) was within normal limits.  The diagnoses listed right thoracolumbar scoliosis (existed prior to enlistment [EPTE], service aggravated) and lumbar syndrome (EPTE, service aggravated).  The orthopedic surgeon discussed surgical treatment options and made the CI aware that this was purely elective surgery and was not without risk.  The CI elected to continue to pursue conservative treatment.  In the 11 March 2003 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI complained of right lower back pain, stiffness, and spasms.  Spasms occurred 1-2 times a month and could last for several days.  He denied pain radiation or current treatment.  The CI reported the condition did not require bedrest and did not cause any functional impairment or lost time from work.  The physical examination documented a normal posture and gait.  The thoracic spine examination revealed “a right hump” with no muscle spasms, ankylosis (joint stiffening or immobility), or tenderness.  There was radiation of pain on movement.  The lumbar spine examination revealed no muscle spasms, ankylosis, tenderness, or radiation of pain on movement.  The straight leg tests were negative and there were no signs of radiculopathy (nerve root irritation or injury).  The lumbar spine range of motion (ROM) was flexion of 95, extension of 35, bilateral lateral flexion of 40, and bilateral rotation 35 of degrees.  There was pain at 35 degrees of left rotation, but it did not prevent full ROM.  Strength and sensation was normal.  A thoracic spine X-ray revealed thoracolumbar scoliosis convex to the right.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5295 code (lumbosacral strain) citing the condition existed prior to service.  The VA did not service connect the back condition under the 5295 code (lumbosacral strain) based on the VA C&P examination 2 months after separation, citing the mild scoliosis, existed prior to service and lack of evidence that the condition permanently worsened as a result of service.  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), dorsal spine ankylosis (5288), lumbar spine ankylosis (5289), limitation of dorsal spine motion (5291), limitation of lumbar spine motion (5292), or sacro-iliac injury/weakness (5294) for consideration under the respective codes.  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).  Board members agreed a 10% rating was supported under lumbosacral strain (5295) based on characteristic pain on motion.  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 recommends a disability rating of 10% for the low back condition.  

BOARD FINDINGS:  In the matter of the low back condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5295 IAW VASRD §4.71a.  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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Back Pain with Thoracolumbar Scoliosis	5299-5295	10%	
The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150530, with attachments
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

03 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160019842 (PD201500410)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 10% without re-characterization of the individual’s separation.  This decision is final.  

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.   

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:

CF: 
(  ) DoD PDBR
(  ) DVA