RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01586
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20070316

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Security Forces Apprentice, medically separated for “low back pain due to pars defect and anterolisthesis”, with a disability rating of 20%.  

CI CONTENTION:  The CI made no specific contention.  The 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 - 20070130	VARD – N/A	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5239	20%	No VA Claim in Record	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Low Back Pain Due to Pars Defect and Anterolisthesis.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent back surgery (L5-S1 vertebral fusion) on 15 January 2007.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “grade 1 spondylolisthesis of L5 and chronic low back pain” for PEB adjudication.  At a physical therapy (PT) visit in November 2007, range of motion examination showed forward trunk flexion to 40 degrees (normal thoracolumbar flexion = 90 degrees; normal “trunk” flexion = 60 degrees).  

At the 30 November 2006 MEB NARSUM examination, 2 months before surgery and 4 months pre-separation, the physical examination showed a normal gait with normal neurologic examination.  There was evidence of decreased (4/5) strength of foot flexion, thought to be consistent with an L5 radiculopathy.  The NARSUM examiner noted pain with axial load and trunk rotation that did not correlate with the pathology present.  Surgery (L5-S1 vertebral fusion) was performed on 15 January 2007.  

At the 7 March 2007 neurosurgery follow up examination, 7 weeks post-surgery and 1 week before separation, the CI reported no back pain, occasion right leg pain after activity, and intermittent use of pain medications.  Physical examination showed normal strength in the lower extremities.  The examiner stated that the CI was “doing very well” and cleared her to return to work with a lifting restriction of 50 lbs.  The CI was medically separated on 16 March 2007.  

At the 17 October 2007 Neurosurgery follow up examination, 9 months post-surgery and 7 months after separation, the CI was working as a cashier at Target, and reported return of the back pain and weakness of the left lower extremity.  Physical examination documented normal strength, gait, and no neurologic abnormalities.  There was no VA Compensation and Pension (C&P) in evidence for review.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the low back pain 20%, coded 5239 (spondylolisthesis or segmental instability).  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), reported on the MEB and PT examinations.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).  

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 20150626, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01586.

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,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings