RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01603
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050314

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Utilities Systems Journeyman, medically separated for “chronic low back pain (LBP)” with a disability rating of 20%.  

CI CONTENTION:  The CI is contending for a higher rating.  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 - 20041227	VARD - 20050620	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5241	20%	Degenerative Disc Disease of the Lumbar Spine, Post-Surgical	5241	10%	20050419	
			Surgical Scars on the Low Back	7804	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

LBP.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LBP condition began in October 2003 without specific injury or trauma.  Both radiographic and imaging studies showed arthritis at L4 and L5 S1 and a protruding disk at L5 S1 with an S1 nerve root compression.  The CI underwent a surgical fusion procedure at L5 S1, resulting in no postoperative complications.  Subsequent to surgery, the CI was referred to physical therapy.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “lumbar myelopathy” for PEB adjudication.  The 18 November 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of LBP.  The physical examination showed limited range of motion (ROM) with forward flexion (FF).  The CI also had some mild tenderness to palpation (TTP) over the surgical scar.  
At the 19 April 2005 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported popping and radiating back pain.  He also complained of locking which lasted a couple of hours followed by pain flare-ups precipitated by repetitive physical activities.  He used a cane after surgery and used a back brace intermittently as needed.  The physical exam showed a normal gait and no evidence of radiculopathy.  The ROM was 0-75 degrees of flexion and 0-25 degrees of extension.  There was evidence of painful motion and weakness with repetitive motion.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 20%, coded 5241 (spinal fusion).  The VA rated the LBP condition 10% coded 5241 (spinal fusion), based on the VA C&P examination 1 month after separation, citing greater than 60 degrees but not greater than 85 degrees of FF.  The VA also rated the scars at 10% coded 7084 (scars, unstable or painful), citing four scars, the largest being 13x.3cm in the midline region.  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) and/or muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, reported on the (MEB, NARSUM, VA, all 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), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  The Board concluded there was no evidence to support a rating higher than the rating adjudicated by the PEB.  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 LBP condition.  

BOARD FINDINGS:  In the matter of the LBP 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 modification or re-characterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150624, 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-2015-01603.

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