RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00894
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20071105

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Security Forces Journeyman, medically separated for “chronic low back pain [LBP] with congenital spina bifida occulta L5 only,” with a disability rating of 20%.

CI CONTENTION:  The CI’s condition continues to worsen and negatively impacts daily living.  His 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 - 20070917	VARD - 20080529	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP…	5299-5235	20%	Degenerative Disc Disease L4-5…	5242	10%	20080515	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS: 10%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LBP began as early as December 2004 after heavy lifting and was exacerbated in January 2006 after “wearing new gear.”   Radiographic studies in March 2006 showed a congenital defect (spina bifida occulta) in the lower back as well as an abnormal straightening of the normal curvature of the back, potentially due to spasm or positioning for the study.  Magnetic resonance imaging (MRI) in August 2006 revealed broad-based dorsal bulging of the disk annulus at the L4-L5 level along with a potential growth within the L1 vertebral body, which possibly represented a benign hemangioma (collection of blood vessels).  Evaluation by neurosurgery indicated back surgery might be needed in the future, but was not advised as of the date of examination in September 2006. 

Despite conservative treatment with physical therapy, multiple medications, osteopathic manipulation, bilateral L2, L3 and L4 medial branch nerve blocks and bilateral L4 dorsal ramus nerve blocks, and bilateral L2 and L3 medial branch radiofrequency neurotomies, the CI’s back condition could not be adequately rehabilitated to meet the physical requirements of his military specialty and he was referred for an MEB.  The MEB forwarded “chronic low back pain” and “congenital spina bifida occulta L5 only” for PEB adjudication.

The MEB NARSUM examination on 15 June 2007, 5 months prior to separation, noted results of the physical examination of the back to be within normal limits.  At the time of the orthopedic clinic appointment on 11 July 2007, the CI reported constant aching pain in the back with intermittent stabbing pain down into the buttocks and both legs.  The CI rated the pain severity at 6/10, and indicated he could sit for no more than 30 minutes, stand for no more than 10 minutes, and was limited to walking no more than 200-300 feet.  He was able to drive, but had difficulty with household chores and sleeping.  Physical examination revealed the range of motion (ROM) measurements for forward flexion 50 degrees (normal 90) and extension 10 degrees (normal 30).  Other planes of motion were not reported.  He had no focal motor or sensory deficit in either lower extremity and reflexes were 2+ bilaterally.  Additional bilateral L4 medial branch and bilateral L5 dorsal ramus neurotomies (to interfere with nerve transmission of pain signals) were performed on 23 July 2007; however, the CI still had LBP.     

At the 15 May 2008 VA Compensation and Pension (C&P) evaluation, performed 6 months after separation, the CI denied bowel and bladder symptoms as well any incapacitating episodes in the prior 12 months.  He reported daily moderate back pain with radiation to the buttocks and both legs behind the knees.  Also reported were weekly flare-ups of pain that lasted 1-2 days and were brought on by activity and relieved by rest.  Physical examination showed an absence of spasm, guarding, pain with motion, and tenderness.  Spinal contour and gait were reported as normal, and there was no abnormal curvature of the spine.  Neurologic examination was normal and all planes of motion were measured with full ROMs (90 degrees flexion and 240 degrees combined ROM).  Provocative testing for nerve root impingement was negative for radiculopathy, and a radiologic study showed the congenital spina bifida at L5, but was otherwise normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain 20%, coded 5299-5235 (analogous to vertebral fracture or dislocation), offering no documentation for the basis of that decision.  The VA rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination 6 months after separation, citing “X-Ray evidence of degenerative disc disease with painful motion.”  The Board agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) as reported on the July 2007 orthopedic examination.  There was no documentation of an intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under the formula for that condition, or evidence of ratable peripheral nerve impairment which would provide for additional rating.  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 chronic low back pain.  

BOARD FINDINGS:  In the matter of the chronic low back pain 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 20150606, 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-2015-00894.

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