RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX  	CASE:  PD-2015-01052
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20030618

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Aircraft Loadmaster Journeyman, medically separated for “chronic low back pain” with a disability rating of 10%.  

CI CONTENTION:  The CI made no specific contention.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20030409	VARD - 20041206	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain Status Post Laminectomy	5295	10%	Status Post Decompressive Lumbar Laminectomy, Facetectomy
and Fusion L4-S1 with Disc Protrusion at L4-L5	5241	40%	20040709	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain Status Post Laminectomy:  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent back surgery (L4-Sl decompressive laminectomy, facetectomy, and fusion with rod placement) in September 2000 for congenital spina bifida and degenerative disc disease.  The CI had no complications and reported relief for 6 months.  The next entries for back pain with intermittent radiation occurred in January 2002.  

At primary care visits in October and November 2002, and January 2003, the examiners documented full range of motion (ROM) without addressing spasm or painful motion.  Normal gait was consistently documented at 7 visits between March 2002 and January 2003.  

A 17 January 2003 orthopedic consultation, 5 months prior to separation, noted full ROM and full lateral bending with pain, without addressing spasm.  The 23 January 2003 MEB NARSUM examination noted complaints of pain and paresthesias.  The physical examination showed no spinal tenderness and full ROM, with no neurological deficits.  Nerve tension testing was negative.  During the 18 June 2003 MEB examination (recorded on DD Forms 2697), on the day of separation, the CI reported lower back pain with radiation to the left lower extremity.  The physical examination showed “decreased” ROM with forward flexion and side bending to the left.  

There was no VA Compensation and Pension (C&P) evaluation within 12 months of separation for review.  

The panel directed attention to the rating recommendation based on the above evidence.  The PEB rated the low back pain 10%, coded 5295 (lumbosacral strain) citing chronic low back pain status post [surgery] with “minimal medication requirements and relative functionality.”  The VA rated the low back pain 40% coded 5241 (spinal fusion), based on the VA C&P examination 13 months after separation, citing limited flexion.  At the time of separation in March 2003, the 2003 standards for rating based on ROM impairment were subject to the rater’s opinion regarding degree of severity; whereas, the current standards specify rating thresholds in degrees of ROM impairment.  When older cases have measurements in evidence, the panel reconciles (to the extent possible) its opinion regarding degree of severity for the older spine codes.  Applicable codes include 5292 (spine, limitation of motion, lumbar), 5293 (intervertebral disc syndrome), and 5295 (lumbosacral strain).  

The panel considered the evidence for the back condition using the 2003 VASRD.  In consideration of the 5292 code (spine, limitation of motion of, lumbar), only 1 examination (June 2003 MEB on DD Form 2697) documented “decreased” range of motion without comment as to the severity.  All other examinations documented “full” ranges of motion.  Therefore there was no evidence to support a higher than 10% rating for ‘slight’ limitation of motion.  The panel next considered code 5293 for intervertebral disc syndrome which requires quantification of incapacitating episodes and this information was not in evidence for the panel’s review.  There was no mention of any missed work days or bed rest; only the inability to perform his full military specialty.  The panel also considered code 5295 for lumbosacral strain.  The CI reported painful motion, however there was no evidence of abnormal gait, spasm on extreme forward bending, significant loss of lateral spine motion in the standing position and no evidence that would be considered as “moderate” in support of a higher rating.  None of these coding options afforded a greater than 10% rating advantage to the CI.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic low back pain condition.  

BOARD FINDINGS:  In the matter of the low back condition and IAW the VASRD in effect at the time of separation, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150611, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment

SAF/MRB
XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01052.

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,

XXXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings