RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02188
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040630

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Intelligence Analyst, medically separated for “low back pain [LBP],” 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 - 20040526	VARD - 20041015	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5241	10%	HNP L5-S1; Status Post Discectomy and Fusion with Degenerative Changes	5242-5241	10%	20040813	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: 10%	

ANALYSIS SUMMARY:  

Low Back Pain. Status Post Spinal Fusion.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent back surgery with discectomy and spinal fusion in February 2003.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic low back pain” for PEB adjudication.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated March 2004, 4 months prior to separation, the CI reported back pain with shooting to the shoulders with prolonged sitting or standing or if she bending or twisting.  Physical examination noted well healed surgical scar, intact bilateral reflexes and painful thoracolumbar forward flexion.  Left leg strength was recorded as 4/5.  Thoracolumbar range of motion (ROM) measurements performed by physical therapy (PT) on 13 April 2004 showed, after repetition, flexion of 65 degrees (normal 90) and combined ROM of 190 degrees (normal 240).  The MEB NARSUM examination on 16 April 2004, 3 months prior to separation, noted complaints of chronic pain.  Physical examination showed well-healed surgical scar.  Motor strength was 4+/5 in the lower extremities. The examiner note the PT ROM cited above.  At the 13 August 2004 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported constant mild LBP with radiating symptoms.  Physical examination showed a normal gait and posture.  There was no tenderness or muscle spasms.  ROM measurements considered were flexion of 90 degrees and combined ROM of 240 degrees.  There was no pain with motion.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5241 (spinal fusion), citing no radiculopathy or spasm and flexion limited to 72 degrees.  The VA also rated the back condition 10% coded 5242-5241 (degenerative arthritis-spinal fusion), based on the C&P examination 2 months after separation.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the NARSUM/Physical Therapy examination proximate to separation.  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 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 IVDS).  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  The Board concluded an additional disability rating was not justified on this basis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.  

BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150731, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170004216, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX
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,					       
						      					
Enclosure