RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX 	CASE:  PD-2015-01923
BRANCH OF SERVICE:  Air Force  	SEPARATION DATE:  20050601

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Enlisted Accessions Recruiter, medically separated for “chronic low back pain [LBP] status post right L5-S1 microdiscectomy,” 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 - 20050415	VARD – NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP S/P Right L5-S1 Microdiscectomy	5243	10%	No VA Examination in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic LBP.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI presented to the emergency room on 15 April 2004 with a 2-day history of LBP after lifting a heavy suitcase out of his truck.  He was noted to have neurological changes in a right-sided L5-S1 distribution.  An MRI showed a bulging disc at the same level.  He was treated for pain and referred to neurosurgery.  He was seen 4 days later and treated with a steroid dose pack.  Despite treatment, his symptoms persisted.  A repeat MRI showed impingement of both the left and right S1 nerve roots.  The CI underwent an L5-S1 discectomy on 15 June 2004 (removed herniated disc material pressing on a nerve root or spinal cord).  Following surgery, the CI had persistent pain.  A follow-up visit in neurosurgery documented that he had pain which radiated to both buttocks and slight numbness of both thighs.  However, it was also noted that he was able to walk the entire day without difficulty once he was up and going.  His strength was “good,” but reflexes were reduced.  A 20 August 2004 MRI was suggestive of right-sided epidural fibrosis surrounding the S1 nerve root.  He was treated with oral steroids (to reduce inflammation) and then an injection without resolution of his symptoms.  The 6 October 2004 primary care physical examination, revealed moderate to severe right posterior superior iliac spine tenderness and decreased range of motion (ROM) with flexion and extension of his back.  Strength was reduced for flexion and extension of the left and right knees.  Sensation was decreased to both pinprick and light touch along medial half of right lower extremity and along dorsal aspect of the left lower extremity extending from the great toe proximally (toward the ankle) along first metatarsal area ray of the foot).  Reduced ROM of flexion/rotation was noted, but measurements in degrees were not recorded.  The CI was referred to orthopedics and seen on 16 November 2004.  He reported persistent pain and numbness of both feet.  

The MEB NARSUM on 4 December 2004, 6 months prior to separation, noted continued CI complaints of lower back and right hip pain, difficulty with walking, shooting pains extending from his right buttocks down posteriorly to his right foot, and decreased strength in his right lower extremity.  The MEB physical examination was based on the 6 October 2004 primary care examination noted above.  The 16 December 2004 primary care physical examination showed moderate to severe lumbar tenderness but no muscle spasms.  He had negative testing provocative for nerve root irritation and normal reflexes.  His strength was 4/5 for the right leg and 5/5 for the left.  The CI was noted to be uncomfortable and needed to change position frequently.  At his 9 February 2005 neurosurgery follow-up appointment, the CI reported pain which radiated down the posterior right leg in an S1 distribution which was aggravated by increased activity.  He reported benefit with the previous steroid injection.  The surgeon recorded that there was radicular pain, but did not record if there was a neurological deficit.  An 18 March 2005 addendum to the MEB NARSUM noted that the CI’s condition had not changed since the previous NARSUM was completed.  The Board noted that the 16 December 2004 examination actually showed improvement from the 6 October 2004 examination upon which the MEB NARSUM was based.  Subjectively though, the CI had noted no improvement.  

The CI was evaluated in physical therapy on 22 March 2005.  The examiner noted “moderate” ROM limitation for lower spine flexion, “severe” ROM limitation for extension and minimal limitations in side bending (lateral flexion) and rotation.  An antalgic gait and guarding were present.  No goniometric measurements in degrees were recorded.  Muscle tightness was present, but spasm was not recorded.  Motor function was noted to be 4/5 for L4, 4-/5 for L5, and 4/5 for S1 on the right.  He was able to transfer (from lying to sitting to standing and reversed), but with guarding of the trunk.  The sensory examination was not recorded nor were the reflexes.  It was not noted if the decreased strength was from pain or from a neurological deficit.  There is no record of a VA Compensation and Pension evaluation in evidence.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain status post right L5-S1 micro-discectomy condition 10%, coded 5243 (intervertebral disc syndrome).  Forward flexion was recorded as moderate.  Unfortunately, goniometric measurements were not in evidence.  The Board opined that a moderate level of impairment is most consistent with a limitation in flexion of between 30 and 60 degrees supporting a 20% rating.  Guarding was present.  Although the abnormal gait was not specifically attributed to it, both guarding and an abnormal gait were present and this was consistent with a 20% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the chronic low back pain status post right L5-S1 micro-discectomy condition, coded 5243.  

BOARD FINDINGS:  In the matter of the chronic LBP status post right L5-S1 micro-discectomy condition, the Board unanimously recommends a disability rating of 20%, coded 5243 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic LBP Status Post Right L5-S1 Microdiscectomy	5243	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150629, w/atchs
Exhibit B.  Service 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-2015-01923.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

							Sincerely,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachments:
1. Directive
2. Record of Proceedings

cc:
SAF/MRBR