RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02059
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071115

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Ammunition Specialist, medically separated for “brain disease due to trauma” and “vertebral fracture,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  “I was not evaluated properly for my mental health (PTSD) and TBI.”  The CI’s 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 - 20071005	VARD - 20081202	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Brain Disease Due to Trauma	8045-9304	10%	Migraines (Associated with TBI)	8100	10%	20080326  
20081017	
			PTSD with Cognitive Disorder Associated with the Residuals of TBI	8045	70%		
Vertebral Fracture	5235	0%	Residuals, Fracture C2 with Decreased Sensation on the Left Upper Extremity	5235	20%	20080326	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:    

Brain Disease Due to Trauma.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s “brain disease due to trauma” condition began in August 2005 after a pedestrian motor vehicle accident.  He was unconscious after the event and was hospitalized.  X-rays completed at the time showed a C2 fracture which was treated with a cervical collar and convalescent sleep.  The CI was able to return to duty in October 2005; however, he subsequently complained of headaches and neck pain.  He was diagnosed with post-concussive syndrome.  Despite treatment with specialists, his symptoms persisted and he was referred to the MEB.  The MEB forwarded “chronic headaches secondary to post-concussive syndrome” for PEB adjudication.  

At the 17 August 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported problems with memory, sleep, panic attacks when in crowds, frequent headaches (3-4 times a week) and dizziness.  The 14 September 2007 MEB NARSUM examination, 2 months prior to separation, noted complaints of neck pain with chronic headaches.  The examiner noted that the CI was taking medications with minimal effectiveness for his headaches. 

At the 26 March 2008 VA Compensation and Pension (C&P) neurological disorders examination, the CI reported that he worked as an inspector for a pipe line company for the last 3 years and only missed 2 days of work during that period due to headaches.  The examination was essentially normal.

At the 17 October 2008 VA C&P TBI examination, 11 month after separation, the CI reported a history of 2 brain injury incidents.  He stated that he was exposed to a blast explosion during deployment to Iraq in 2003 that rendered him unconscious and again in 2005 related to the MVA (pedestrian) without loss of consciousness.  He reported problems with memory, headaches, sleep, dizziness and balance.  Physical exam showed normal gait, and normal motor and sensory function.  TBI with residuals was diagnosed as well as headaches, mixed cephalgia with post-concussive and migraine headaches.

The panel directed attention to its rating recommendation based on the above evidence. 
PEB rated the condition at 10% coded analogously 8045-9304 (dementia due to head trauma), citing post-concussive headaches that were non-prostrating, but frequent and severe enough to interfere with performance of duty; with normal imaging and neurological exams.  

The VA rated “migraines,” 10% coded 8100 (migraine headaches); and deferred “residuals, traumatic brain injury” coded 8045 (residuals of TBI), based on the VA C&P examinations 4 and 11 months after separation.  

At the time of the VA rating, code 8045 was modified as ‘residuals of TBI’ and facets were used for rating.  However, the VARSD in effect at the time of separation captured brain injuries under the generic category of brain disease due to trauma (8045).  There are two different scenarios for rating under this code; analogously with purely neurological deficits, or purely subjective symptoms.   In the absence of associated neurological disabilities (seizures, nerve paralysis, etc.), or in the absence of a diagnosis of multi-infarct dementia associated with brain trauma, rating of this condition under 8045-9304 is limited to 10%, and cannot be combined with any other rating for a disability due to brain trauma.  The panel found an absence of evidence that would support any neurological disability, and therefore, only a 10% rating was supported. 

The panel considered the 8100 code; however, the panel concluded the use of this code provided no additional benefits to the CI.  The panel agreed that a 10% rating, but no higher, was justified for the headache condition under code 8045, and there was no justification for a higher rating under the 8100 code since prostrating attacks were not present.  There were no additional applicable codes to consider for rating the condition.

After due deliberation in consideration of the preponderance of the evidence, the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication of the brain disease due to trauma condition.
[Cervical] Vertebral Fracture.  According to the STR and MEB NARSUM, the CI sustained a non-displaced vertebral fracture in August 2005 after a pedestrian motor vehicle accident.  The neck fracture healed; however, he continued to have neck pain, and was referred to the MEB.  The MEB forwarded “chronic neck pain secondary to soft tissue injury of C-2” for PEB adjudication.  

At the 17 August 2007 MEB examination (recorded on DD Forms 2807-1 and 2808) dated August 2007, 3 months before separation, the CI reported that his neck pain interfered with sleep, and that he had numbness in his left thumb.  Physical exam showed cervical spine with full ROM.  The spine and neurologic evaluations were marked as normal. 

The 14 September 2007 MEB NARSUM examination, 2 months prior to separation, noted complaints of chronic neck pain and numbness in the neck and left hand.  Physical examination showed normal sensory and motor exams.  Range of motion (ROM testing showed flexion of 30 degrees (normal 45) and combined cervical spine ROM of 195 degrees (340), all ROM movements were limited by pain. 

At the 26 March 2008 C&P general examination, 4 months after separation, the CI complained of pain with any movement of his neck and at times the pain was accompanied by numbness in the neck and in the left hand.  The CI reported that the medication prescribed for his back pain gave him headaches.  Physical examination of the neck revealed slight tenderness to palpation.  ROM testing showed flexion of 20 degrees and combined cervical spine ROM of 240 degrees.  Motor and sensory examinations were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 0%, coded 5235 (vertebral fracture or dislocation), citing pain-limited, non-compensable motion restriction, without tenderness or spasm.  The VA rated the neck condition 20% coded 5235 (Vertebral fracture or dislocation), based on the C&P examination 3 months after separation, citing forward flexion limited to 20 degrees.   

The panel majority agreed that a 20% rating, but no higher, was justified for limitation of flexion greater than 15 degrees but not greater than 30 degrees as reported on the MEB NARSUM and VA examinations proximate to separation.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula, or evidence of ratable peripheral nerve impairment which would provide for additional rating.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 20% for the neck condition, coded 5235.  

BOARD FINDINGS:  In the matter of the “brain disease due to trauma” condition and IAW VASRD §4.124a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the neck condition, the panel majority recommends a disability rating of 20%, coded 5235 IAW VASRD §4.71a.  The single voter for dissent recommended no change in the PEB adjudication of the vertebral fracture condition and did not elect to submit a minority opinion.  There were no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Brain Disease Due to Trauma	8045-9304	10%	
Vertebral Fracture	5235	20%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150629, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010037, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:  

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure