RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00835
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050416

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Health Care Specialist, medically separated for “chronic radiating low back pain,” with a disability rating of 0%.

CI CONTENTION:  The CI contends “Review All Conditions.” 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 - 20050218	VARD - 20140206	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Radiating Low Back Pain	5243	0%	Degenerative Disc Disease L4-L5	5003-5237	10%	20131218	
Multilevel Degenerative Joint Disease of the Cervical Spine	Not Unfitting	No VA Placement	
Gastroesophageal Reflux Disease (GERD)			
Acne, Grade II			
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:   

Chronic Radiating Low Back Pain.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in February 2000 when she was involved in a motor vehicle accident (MVA). A 2002 lumbar spine magnetic resonance imaging (MRI) study showed degenerative disc disease at L4-L5 and L5-S1 with an L4-L5 central disk extrusion with contact of the L5 nerve root and an L5-S1 disk extrusion with contact of the S1 nerve root.  A note dated 1 October 2004 indicated the CI had a 2-month history of sharp thoracic-spine pain without trauma in the morning with radicular symptoms into the left upper extremity and ring finger.  The CI took Vioxx (rofecoxib, a nonsteroidal anti-inflammatory drug (NSAID)) for pain relief.  On examination she had full bilateral upper extremity and C-spine ranges-of motion (ROMs) and tenderness to palpation of T4-T7, left greater than right.  Neurologic evaluation was unremarkable.  TENS [transcutaneous electric nerve stimulation] and steroid injections were not helpful.  

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 “multilevel lumbar degenerative disk disease with extrusion” for PEB adjudication.

During the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 15 October 2004, 7 months prior to separation, the CI reported recurrent back pain with numbness and tingling.  Physical examination showed tenderness to palpation, no spasm, and a full ROM.  The 29 October 2004 examination revealed no tenderness to palpation and the ROM was within normal limits.   The examiner noted the CI had symptoms of radiculitis without clinical history or physical examination indicative of radiculopathy or need to test with electrodiagnostic (EMG (electromyogram)/nerve conduction) studies.  Neurosurgical evaluation on 4 November 2004 noted recent X-rays of the lumbosacral spine confirmed degenerative disc disease, severe at L5-S1 and moderate at L4-5.  Examination revealed full ROMs of the lumbar and cervical spine and a trigger point near the sacroiliac joint on the left.  Fusion surgery was not recommended because of the CI’s young age and multilevel degenerative disc disease.     

The MEB NARSUM examination on 15 December 2004, 6 months prior to separation, noted complaints of intermittent dull throbbing pain at a level of 5/10 that lasted 6 hours per day and was worsened by standing for more than 1 hour, carrying more than 25 pounds, or sitting for more than 2 hours.  The pain was improved by changing positions, methocarbamol (a muscle relaxer) and narcotics.  The CI was unable to lift sand bags, wear a rucksack, carry litter patients, stand in the operating room for more than 1 hour, do sit-ups or push-ups or run quickly.  Physical examination revealed a full ROM.  Straight leg raise testing (to determine nerve root irritation) was negative; and motor strength and sensation were intact in the bilateral lower extremities.  On examination in February 2005 she reported no pain and denied radiation of pain, saddle anesthesia, or bowel or bladder incontinence, but stated she stayed in bed the prior weekend.  She had a full ROM and mild tenderness to palpation over L4-S1.  Treatment consisted of replacing Mobic (meloxicam, an NSAID) with Celebrex (celecoxib, an NSAID) and Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever).  On examination the CI had full ROM and tenderness to palpation over L4-S1.  A VA Compensation and Pension (C&P) evaluation was not performed until almost 8 years after separation.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating for the chronic radiating low back pain condition under code 5243 (intervertebral disc syndrome), citing full range of motion, no tenderness, and no clinical signs of radiculopathy.  The VA assigned a 10% rating using an analogous code 5003-5237 (Arthritis, degenerative (hypertrophic or osteoarthritis)-Lumbosacral strain), based on the VA examination, almost 8 years post-separation.  There was no limitation of thoracolumbar spine motion to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine; however, an examination noted the presence of localized tenderness.  A 10% rating was therefore warranted.  There was no spasm/guarding causing altered gait or contour to support a rating higher than 10%.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).  Radiographic studies supported some level of radicular nerve irritation or involvement, but physical examinations proximate to separation revealed no objective findings of radiculopathy that would impact duty performance.  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 no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  The Board therefore concluded that 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 recommends a disability rating of 10% for the chronic low back pain condition, coded 5099-5003.  

Contended PEB Conditions- Multilevel Degenerative Joint Disease of the Cervical Spine, GERD, and Acne, Grade II.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or explicitly implicated in the commander’s statement, although the commander noted “degenerative bone disease, had resulted in 4 bulged disks,” which suggests involvement of both the cervical spine and lumbar spine.  However, none of the contended conditions were judged to fail retention standards.  

Multilevel Degenerative Disc Disease of the Cervical Spine.  At a physical therapy clinic visit on 1 October 2004, the CI reported left upper extremity pain with left upper extremity radicular symptoms.  On examination she had full ROM of the both upper extremities and cervical spine.  Neurologic evaluation was unremarkable and Spurling’s test (to determine nerve root irritation) was negative.  A neurosurgical evaluation on 4 November 2004 indicated the CI had neck pain for 4 months without an inciting injury or accident and was associated with pain in the left shoulder, down the arm into the right finger.  There was no numbness or weakness.  Treatment consisted physical therapy and occasional pain medication.  She continued to work as an ENT (ear, nose and throat) technician and had not missed any work in the prior year.  An MRI of the cervical spine demonstrated a right sided C6-7 foraminal herniated nucleus pulposus versus osteophyte, which did not correlate with left sided symptoms.  Degenerative disc disease, which was worse at that level, was present throughout.  She had some radicular features, but had no objective evidence of radiculopathy and was not a candidate for a surgery.  

GERD (Gastroesophageal Reflux Disease).  In November 2004 the CI reported intermittent nocturnal pyrosis (heartburn) for 2 years; however, she had findings consistent with a Mallory Weiss tear (of the mucosa of the esophagus) and erosive esophagitis in October 1999.  She took Aciphex (rabeprazole) and TUMS (calcium carbonate) daily and took tetracycline (an antibiotic) for 2 months for acne (see below).   The gastroenterologist modified the Aciphex protocol and reviewed certain food avoidance, elevation of the head of her bed, and smoking cessation.   Esophagogastroduodenoscopy on 15 November 2004 revealed erosive esophagitis.  

Acne, Grade II.  The NARSUM indicated the CI had acne prior to service.  A note dated 1 November 2004 indicated the CI took tetracycline for 2 months and her gastrointestinal symptoms had not worsened.

There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic radiating low back pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended cervical spine, GERD, and acne 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 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	
Chronic Radiating Low Back Pain	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150605, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170011692, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure