RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02034
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080624

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Cavalry Scout, medically separated for “chronic low back pain due to Tarlov cyst” and “chronic post-concussive headaches,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION:  Contended hearing loss, chronic low back pain and post-concussion headache conditions.  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 – 20080227	VA - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5299-5236	10%	No VA Exam in Evidence	
Chronic-Post-Concussive Headaches…	8045-9304	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:

Chronic Low Back Pain.  According to the service treatment record (STR), and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic low back pain (LBP) condition began approximately in May 2007 after a military vehicle accident.  Lumbar spine X-rays on 23 May 2007 were normal.  At the time of the emergency rotational clinic appointment on 25 May 2007, 13 months prior to separation, the CI reported persistent LBP since being struck in the head by a Bradley fighting vehicle hatch.  He complained of midline 7/10 LBP at rest which was exacerbated by activity.  The CI experienced transient loss of consciousness (LOC) and a single episode of involuntary defecation with the initial impact injury.  He denied subsequent radiculopathy (nerve root irritation or injury), paresthesia (abnormal sensation, tingling, burning, prickling), or bladder dysfunction.  On examination, the lumbosacral spine revealed a normal curvature with no step deformity, ecchymosis (bruising) or skin abnormalities.  Gait was normal.  There was mild spinous process and L4-S1 paraspinal muscle tenderness with right L4-S1 paraspinal muscle spasm.  The range of motion (ROM) was full with pain on lateral flexion.  Waddell’s signs (psychogenic, or nonorganic, manifestations of pain) were negative.  Strength, sensation, and deep tendon reflexes (DTRs) were normal.   

The 15 August 2007 lumbar spine magnetic resonance imaging (MRI) revealed an 8.3 x 2.5 cm Tarlov cyst (typically asymptomatic dilation of posterior spinal nerve root sheaths filled with cerebrospinal fluid) posterior to the S2-S5, mild L5-S1 disk desiccation,  and no disk herniation or neural foraminal (nerve root opening) narrowing.  The 20 August 2007 pelvis MRI revealed an S2-S3 Tarlov cyst.  At the 6 September 2007 neurosurgery consultation, 9 months prior to separation, the CI reported being struck on the head 3 months prior with a Bradley hatch.  He reported transient LOC and bowel and bladder incontinence with this incident.  The CI complained of constant and severe LBP with associated legs ''going to sleep" when he laid down at night.  He denied current bowel or bladder issues or numbness.  The physical examination documented a normal gait.  The back examination revealed tenderness at L-4 with no wasting.  Strength, sensation, and DTRs were normal and pathologic reflexes were absent.  The examiner recounted the findings of the MRI.  The assessment documented “It is very doubtful that the cyst is contributing to his LBP.  This is an incidental finding and is congenital [inborn] in nature.  Pt’s back pain should improve with conservative medical management.  No Neurosurgical intervention indicated.  Patient is cleared to resume full Army activities without limitations from a Neurosurgical standpoint.”  

During the 16 October 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months before separation, the CI reported lower back pain since a Bradley hatch hit him on the head.  The 3 January 2008 MEB NARSUM examination, 6 months before separation, noted complaints of constant LBP, exacerbated by activity.  Physical examination revealed slight left sacroiliac joint and L1 to the sacrum tenderness with bilateral spasms, but gait was normal.  The pain-limited goniometer measured thoracolumbar ROM values were flexion of 75 (90 normal), and a combined ROM of 185 degrees (240 normal).  Strength, sensation, and DTRs were normal.  The examiner documented “He is neurologically intact, according to Neurology's exam.”  The examiner recounted the findings of the X-rays and MRIs and cited the Neurosurgery and Neurology consultations.  The diagnosis listed chronic LBP pain due to Tarlov cyst.  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded analogously to 5236 code (sacroiliac injury and weakness) citing flexion greater 60 degrees, but not greater than 85; and spasms without altered gait.  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) as reported on the MEB NARSUM examination.  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 on this basis.  There was no documentation of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disc disease.  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 low back condition.  

Chronic Post-Concussive Headaches.  According to the STR and the MEB NARSUM, the CI’s chronic post-concussive headaches condition began approximately in May 2007 after a military vehicle accident.  During the 16 October 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months before separation, the CI reported headaches since a Bradley hatch hit him on the head.  At the 3 January 2008 neurology clinic evaluation, 5 months before separation, the CI reported being struck on the head with a Bradley hatch and experiencing complete LOC for seconds to minutes.  Since that incident, the physician documented he had “…been having headaches up to several times per day, tend to be right temple, behind the ear, behind the eyes, last up to a couple of hours, bad enough daily to lay down, + photo/phonophobia, no nausea.  He may note twitching right side of the face/around the right eye prior to bad headaches.  He may have milder shorter duration headaches daily.  He will usually take Motrin, lay down.  He has not been prescribed preventive meds, abortive meds, or had to go to the ER/get a shot…He has had multiple other head injuries with complete LOC 6-7 times, mainly from football, usually a minute or less, associated with headache.”  The mental status findings revealed normal affect, orientation, memory, attention, speech and fund of knowledge.  The physical examination documented a normal gait.  Strength, muscle bulk, muscle tone, sensation, cranial nerves, spinal accessory nerves, and DTRs were normal and pathologic reflexes were absent.  The assessment documented “Headaches post head injury, migraine features, incapacitating 2/week, fail retention standards.  He has not had prostrating headaches.  He has had multiple other mild concussions, with no other sequelae.  He has not attempted headache prophylaxis, or prescription abortive headaches medication, will initiate Pamelor, Imitrex.  There is reasonable expectation of decreased headache frequency with medication, but it may take several months, possibly several medication changes, dose adjustments.  I would not recommending delaying board to complete trial of medication for headaches.”  

The MEB NARSUM recounted the history and interventions.  The CI stated, “…that he has had concussions in the past while playing sports, but after this concussion, he notices headaches to be more continuous and every day.  …Patient states that he does get nauseated every other day, and this is associated with the occipital headaches, which he gets an aura of eye and chin twitching for him to know when the bad headaches are coming.”  The physical examination revealed that strength, sensation, and DTRs were normal.  The examiner documented “He is neurologically intact, according to Neurology's exam.”  The examiner recounted the findings of the X-rays and MRIs and cited the Neurosurgery and Neurology consultations.  “His headaches are post head injury with migraine features that are incapacitating due to being up to a week, with no evidence of prostrating headaches. …For his headaches, his condition is somewhat unstable due to starting a prophylaxis medication at this time I am not able to state if he is compliant, due to he is just starting medication, and his prognosis is fair.”  The diagnosis listed post-concussion headaches with migraine-like features.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the post-concussive headaches condition 10%, coded 8045-9304 (residuals of traumatic brain injury [TBI]-dementia due to head trauma) citing chronic post-concussive headaches with migraine-like features, and no prescription of preventative medications, abortive medications or visits to the ER.  The TBI-associated chronic post-concussive headaches condition was subsumed by the PEB under the 8045 rating.  While there was evidence of physical dysfunction, with subjective symptoms (chronic post-concussive headaches), there was no evidence of cognitive impairment or emotional/behavioral dysfunction as residuals of TBI.  Purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, will be rated 10% and no more under diagnostic code 9304.  This 10% rating will not be combined with any other rating for a disability due to brain trauma.  Ratings in excess of 10% for brain disease due to trauma under diagnostic code 9304 are not assignable in the absence of a diagnosis of multi-infarct dementia associated with brain trauma.  While the post-concussion headaches were characterized as having “migrainous features,” the CI was not diagnosed with migraine headaches.  Under code 8100 (migraine [headaches]) a rating of 10% requires characteristic prostrating attacks averaging one in 2 months over a several month period.  The neurology evaluation documented “He has not had prostrating headaches” and the NARSUM documented “no evidence of prostrating headaches.”  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 post-concussive headache condition.  

BOARD FINDINGS:  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the chronic-concussive headaches condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are 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 20150720, w/atchs
Exhibit B.  Service Treatment Record

	

AR20170010026, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,