RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02160
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060712

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Aircraft Electronic and Environmental Systems Craftsman, medically separated for “low back pain” with a disability rating of 20%.   

CI CONTENTION:  “Review all 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 at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  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 - 20060531	VARD - 20071019	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain 	5243	20%	Bone Spurs L3-L4, Degenerative Disc Disease L3-L4 and Rupture Disc L3-L4	5242	10%	20070828	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s “low back pain” condition began in October 2005 without any specific injury.  Magnetic resonance imaging (MRI) dated 2 November 2005 showed central disc herniation at L3-4 and bony spurring and a slight disk bulge at L4-5. Treatment consisted of Medrol (prednisolone, a steroid) and Ultram (tramadol, a narcotic-like medication).  

On 9 January 2006 the CI was noted to be taking as many as four Vicodin (hydrocodone, a narcotic and APAP (acetaminophen, a pain reliever) for pain relief at times for pain of 6-7/10.  Therefore, the prescription was changed to Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever) to which he started to build tolerance within 2 weeks.  A pain management consultation on 2 February 2006 noted the CI had lower back pain that radiated to both lower extremities along the L4-5 dermatomal distribution with associated numbness and tingling to his feet.  The examiner reported that an electromyogram (EMG) dated 5 January 2006 revealed findings consistent with bilateral L4 root irritation, but insufficient to diagnose radiculopathy.   An epidural steroid injection (ESI) were given on 8 February 2006 and at a follow-up visit on 15 March 2006 the use of Lidoderm (lidocaine, an anesthetic) and a transcutaneous electric nerve stimulation (TENS) unit were offered for treatment of his pain as well the recommendation to taper the Percocet.    

At the time of the physical therapy clinic appointment on 20 March 2006, 4 months prior to separation, the examiner recorded thoracolumbar range of motion (ROM), after three measurements, using a bubble inclinometer for all but lateral flexion (used a goniometer).  Results showed flexion of 42, 43, 43 degrees (normal 90) and combined ROM of 155 (normal 240), with all motions limited by pain.  The CI received another lumbar ESI on 5 April 2006.  

The 7 April 2006 MEB NARSUM examination, 3 months prior to separation, noted complaints of low back pain, confined to L3-5 region and bilateral leg numbness with standing more than 10 minutes.  The pain was rated 6-7/10 (10 being the worst pain), down to 4/10 with medication (Vicodin).  Physical examination showed a mild decrease in ROM due to the complaint of pain, and mild tenderness to palpation over the L4 region.  Straight leg raising was negative and bilateral lower extremity strength was 5/5.  Pulses were 2+ throughout; reflexes were absent bilaterally at the knees. There was no clubbing, cyanosis or edema in the extremities.  On 19 April 2006 the CI reported radiating pain down the lower extremities improved with the ESIs, but the CI continued to complain of pain isolated in the lower back region.  The CI was prescribed Dilaudid 
(hydromorphone, an opioid/narcotic) on 1 May 2006 after the CI wanted his pain medications increased.  Another ESI was given at the L5-S1 level on 5 May 2006 and on 15 May 2006 he reported overall improvement of the LBP and 95% improvement in his leg pain.  The CI was to continue physical therapy, TENS treatment, and non-opioid pharmacotherapy management with NSAIDs (nonsteroidal anti-inflammatory drugs). 

At the 21 August 2007 VA Compensation and Pension (C&P) evaluation and the 28 August 2007 VA joint examination, 13 months after separation, the CI reported low back pain with no history of trauma or radiation of pain.  Physical examination showed normal gait and posture with a ROM of 80 degrees forward flexion (normal 90) and 190 degrees combined (normal 240); all were without pain on motion or loss of motion with repetition.  Deep tendon reflexes were all 2+, and there was no spasm or guarding.  However, the examiner answered yes to whether there was muscle spasm, localized tenderness or guarding severe enough to be responsible for abnormal gait or abnormal spinal contour. Radiographic (X-ray) studies of the lumbosacral spine dated 28 August 2007 showed narrowing of the disc spaces from L3 to S1, which were most marked at L4 and L5, with sclerotic changes at the posterior elements of L4 and L5.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the “low back pain with bilateral leg paresthesias” condition 20%, coded 5243 (intervertebral disc syndrome).  The VA rated the “bone spurs L3-L4, degenerative disc disease L3-L4 and rupture disc L3-L4 condition” 10%, coded 5242, (degenerative arthritis of the spine), citing forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees.  

The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees), reported on the  physical therapy examination.  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 that condition.  The panel concluded there was no evidence to support a rating higher than the rating adjudicated by the PEB.  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 pain” condition.  

BOARD FINDINGS:  In the matter of the low back pain 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 20150717, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 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-2015-02160.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings