RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-0961
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070114

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Light Wheel Mechanic, medically separated for “chronic low back pain,” with a disability rating of 10%.  

CI CONTENTION:  His condition (back and right leg pain) continues to worsen and negatively impact his daily activities.  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 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 - 20061018	VARD - 20080104	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5241	10%	DDD of the Lumbar Spine s/p L-Spine Discectomy and Fusion 	5243	20%	20060914	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain Condition.  According to service treatment records and the medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain condition began in July 2003 while moving equipment.  Magnetic resonance imaging (MRI) studies in April 2005 showed bulging intervertebral discs at L4-5, and L5-S1 with narrowing of the neuroforamina (space through which the spinal nerve root passes).  The CI underwent back surgery with L5/S1 fusion with anterior cage in May 2005 for multilevel disk disease with a right nerve root impingement at L5-S1.  The CI had return of back pain, pain radiating into the legs and left thigh numbness following surgery.  Computed tomography (CT) studies in November 2005 showed mild bulging intervertebral discs at L4-5 and L5-S1 without narrowing of the neuroforamina.  Radiographic studies in June 2006 showed no significant degenerative changes at L5-S1 and no significant narrowing of the neuroforamina.  The range-of-motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Thoracolumbar ROM
(Degrees)	PT/MEB ~6 Mos. Pre-Sep	VA C&P ~12 Mos. Post-Sep	
Flexion (90 Normal)	65	90	
Combined (240)	>150 ; <235	240	
Comments:  	Painful motion, tenderness; see text	No spasm or tenderness; no pain on ROM; flattening of lumbar lordosis	
§4.71a Rating	10% (PEB 10%)	0%-20% (VA 20%)	

At the MEB examination dated 25 August 2006, 4 months prior to separation, the CI reported chronic low back pain that increased with overuse (walking excessively or ascending inclines or stairs) which caused pain down his left upper thigh.  There was also occasional pain down the right leg.  The examiner indicated that “even at 7 months post operatively, the fusion was incomplete.”  Focused physical examination from Spine/Neurosurgery documented well healed scars on his right hip and abdomen with tenderness around the L4-5 and L5-S1 portions of his back.  Leg raises and sciatic nerve tension tests (for radiating symptoms) were positive.  The Physical therapy (PT) pain-limited ROMs, as charted above, were noted in the NARSUM.  

At the VA Compensation and Pension (C&P) examination on 3 December 2007, performed 12 months after separation, the CI reported low back pain and stiffness that limited his walking to 30 minutes, sitting to 2 hours, and moderate effect on his exercise and daily activities.  He was unable to engage in any form of high impact activity due to pain.  He denied radiating symptoms.  Physical examination showed normal gait, with no paraspinal muscle spasm or pain on motion; however, there was flattening of the normal lumbar lordosis (spinal contour).  There were normal reflexes, normal strength testing, and examination maneuvers for radicular signs were negative.  There was no tenderness and normal ROM (without pain on motion or repetition) as in the chart above.  Radiographs documented surgical changes and confirmed flattening of the normal lumbar curve.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 10% coded 5241 (spinal fusion), citing painful limitation of motion and tenderness.  The VA rated the chronic low back pain condition 20% coded 5243 (intervertebral disc syndrome), based on the VA C&P examination 12 months after separation, citing flattening of normal lumbar lordosis.  The Board deliberated on the interpretation and probative value of the examinations in evidence and the totality of the record.  The source MEB/PT examination was closest to separation and met no higher than the 10% criteria for ROM (forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees).  The VA examination was much more remote from separation and although there was an abnormal spinal contour noted, there was scant evidence that it resulted from muscle spasm or guarding.  The Board adjudged that the Service examinations had the highest probative value for rating at separation.  

There was no documentation of incapacitating episodes which would provide for a higher rating under that formula or evidence of ratable peripheral nerve impairment which would provide for additional rating.  There was no associated radiculopathy or fixed neurologic deficit for separate peripheral nerve rating.  While the CI may have experienced intermittent radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairments such as weakness with a direct impact on fitness that were separately functionally impairing for duty.  The Board therefore concluded that 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 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 chronic 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 20150602, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160017821 (PD-2015-00961)

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, I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA