RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02137
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081220

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantryman, medically separated for “lumbar degenerative disc disease” with a disability rating of 0%.

CI CONTENTION:  The CI made no specific contention.  The CI’s complete submission is 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 - 20071120	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar Degenerative Disc Disease…	5299-5242	0%	No VA Exam in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:

Lumbar Spine Degenerative Disc Disease (DDD).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s lumbar spine condition insidiously began in 2007 while at the same time being treated for left foot numbness.  Electrodiagnostic studies revealed an S1 radiculopathy and an MRI revealed disc herniations of the lower thoracic and lower lumbar spine.  Despite profiled restrictions, the CI’s condition did not result in improvement sufficient to allow unrestricted duty.  

During an electromyogram (EMG) and nerve conduction study on 1 June 2007, 7 months prior to separation, the CI complained of low back pain radiating down the right leg and numbness in left toes.  He denied any weakness or bowel/bladder incontinence.  Study results revealed an acute lumbar radiculopathy at the L5 more than S1 level on both right and left sides.  At an orthopedic examination on 20 July 2007, 3 months prior to separation, the CI reported low back pain.  The physical examination (PE) revealed a normal gait and posture with normal thoracolumbar range of motion (ROM); painful motion was not cited.  Motor strength of both lower extremities were normal and there was decreased sensation about the right knee and left foot as well as both lower legs.

The MEB NARSUM examination dated 14 November 2007, 1 month prior to separation, noted complaints of low back pain.  His PE did not reveal localized tenderness, spasm, or guarding.  Lower extremity motor strength and sensation was normal.  He could normal heel, toe and tandem walk.  Thoracolumbar ROM was decreased and painful; flexion at 65 degrees (normal 90), extension at 15 degrees (normal 30), right and left lateral flexion at 20 degrees each (normal  30), and normal bilateral rotation at 30 degrees each direction.  The combined ROM was 180 degrees (normal 240).  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 lumbar spine condition at 0%, coded analogously as 5242 (degenerative arthritis of the spine).  The panel agreed that the MEB NARSUM examination proximate to separation provided the justification for a 10% rating based upon thoracolumbar flexion of 65 degrees (greater than 60 degrees, but less than 85 degrees).  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.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the lumbar spine condition, coded 5299-5242.

PANEL FINDINGS:  In the matter of the lumbar spine condition, the panel unanimously recommends a disability rating of 10%, coded 5299-5242 VASRD §4.71a.  There are 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, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Lumbar Degenerative Disc Disease 	5299-5242	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150802, w/atchs
Exhibit B.  Service Treatment Record

AR20170010047, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

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

Sincerely,	
Enclosure