RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00828
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20090530

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an E5, Logistics Vehicle Systems Operator, medically separated for “low back pain” with a disability rating of 10%.  

CI CONTENTION:  “I would like…my case evaluated due to spinal stenosis.”  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 on 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 - 20090324	VARD - 20090926	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5237	10%	Spinal Stenosis (Low Back)	5238	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: NSC	

ANALYSIS SUMMARY:  

Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain condition began in approximately 2003 without any specific injury or trauma.  The CI was discharged in 2005 and reentered service in 2006.  A lumbosacral spine X-ray on 4 August 2006 was normal.  A 27 December 2007 lumbar spine X-ray was unremarkable except for mildly increased L5 posterior elements sclerosis (pathological thickening).  Lumbar spine diagnostic imaging (MRI) on 2 April 2008 showed multilevel minimal to mild disc bulging, with mild-to-moderate neural foraminal (nerve root opening) stenosis (narrowing).  There was no significant central spinal canal stenosis.  From 2006 until 2009, the CI was seen by orthopedics, physical therapy (PT), and pain management.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred for an MEB.  The MEB forwarded “lumbago” for PEB adjudication.  During the 10 February 2009 NARSUM, 4 months before separation, the CI reported onset of low back pain in 2003 without specific injury.  In 2006 he experienced increasing back pain as well as right leg pain and numbness.  The CI denied bowel or bladder problems.  He did not experience significant improvement with conservative management which included activity modification, PT, chiropractic care, and three epidural steroid injections by pain management.  The back examination revealed lumbosacral spine (L4-S1) spinous process, and paraspinal region, tenderness.  There was no deformity nor were there muscle spasms.  Back range of motion (ROM) was “within normal limits.”  The straight leg raise tests (assess for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) were negative.  Strength, sensation, pulses, and deep tendon reflexes were normal.  The CI failed to report for his VA Compensation and Pension evaluations.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5237 code (lumbosacral strain) citing low back pain.  The VA did not service connect the back under the 5238 code (spinal stenosis) based on the STR.  Although there was insufficient limitation of motion to support a minimum rating, the Board agreed a 10% rating was justified for the presence of tenderness.  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.  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 low back pain condition.  

BOARD FINDINGS:  In the matter of the low back pain 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 20150530, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 23 Mar 17

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN 
		- XXXXXXXXXXXXXXXXXX, former USMC 
		- XXXXXXXXXXXXXXXXXX, former USN 
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN

						  XXXXXXXXXXXXXXXXXX
	     				  	  Assistant General Counsel
						  (Manpower & Reserve Affairs)