RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01833
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040310

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve O2, Field Artillery Officer, medically separated for “chronic low back pain status post lumbar interbody fusion L5-S1,” with a disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  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 - 20031016	VARD - 20040504	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain Status Post Lumbar Interbody Fusion L5-S1	5299-5241	10%	Postoperative Residuals, Fusion, L5-S1, with Degenerative Joint Disease, Lumbar Spine 	5242-5241	10%	20031203	
			Scar, Residual, Back Surgeries	7805	0%	20031203	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Low Back Pain Status Post Lumbar Interbody Fusion L5-S1.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent back surgery with discectomy in July 2002 and L5-S1 fusion in January 2003 for herniated lumbar discs.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “lumbar degenerative disc disease with low back pain” for PEB adjudication.  

The MEB NARSUM examination on 13 May 2003, 10 months prior to separation, noted complaints of low back pain and left lower extremity sciatic pain.  Physical examination showed a normal gait without difficulty on heel walk, toe walk or tandem gait.  Straight leg raise maneuver (SLR – provocative test for radicular symptoms) was negative.  There was a well-healed surgical scar and myofascial back tenderness to palpation.  Thoracolumbar range of motion (ROM) measurements showed flexion of 80 degrees (normal 90) and extension of 15 degrees (normal 30).  

At the 3 December 2003 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported 2-3/10 constant pain, which increased to 6/10 sharp pain two times per week with normal daily activity.  The CI also complained of left leg pain two times per month lasting for approximately 1-day; however, his gait was not affected.  The CI could not perform any strenuous activity, running, or lift greater than 30 pounds.  On examination, there was a normal gait.  ROM showed active flexion to 90 degrees (normal 90) and a combined ROM of 240 degrees (normal 240).  The back was tender to palpation and was weak throughout ROM when resistance was applied.  Fatigability was noted with repetitive use.  Pain was noted to increase throughout ROM with repetitive use.  Provocative testing (Lasegue’s sign) for radicular signs showed increased back pain.  Reflexes, motor, and sensation testing were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5241 (spinal fusion), citing forward flexion of 80 degrees.  The VA also rated the low back condition 10%, coded 5242-5241 (degenerative arthritis of the spine and spinal fusion) based on the VA C&P examination 3 months after separation, citing painful motion and tenderness.  The VA additionally assigned a 0% rating using code 7805 (other scars) for a non-tender scar.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) reported on the NARSUM examination, or painful motion/tenderness on the VA evaluation.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  There was no associated radiculopathy for separate peripheral nerve rating.  While the CI may have experienced 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 impairment (such as weakness) that directly impacted fitness for duty.  The Board therefore concluded that an 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 condition.  

BOARD FINDINGS:  In the matter of the low back 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 20150622, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

20 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170001973 (PD201501833)

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