RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02228
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20090803

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, Boatswains Mate, medically separated for “chronic 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(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 - 20090408	VARD - 20091204	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5237	20%	S/P Lumbar Laminectomy with Scar	5239	20%	20090910	
Spinal Central Canal Stenosis	Cat II					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain S/P Laminectomy and Discectomy.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain condition began in 2003 after lifting heavy lines aboard ship.  An X-ray series on 16 June 2006 demonstrated narrowing of the posterior intervertebral disc height at L5-S1.  A note dated 26 June 2006 indicated the CI had right foot pain that radiated into the right buttock and magnetic resonance imaging was positive for an L4-L4 and L5-S1 herniated nucleus pulposus with stenosis.  In early 2007 he had an exacerbation of the low back pain that was treated with physical therapy and an epidural steroid injection that worked well.  Pain recurred in January 2008.  Subsequently, the CI underwent an L4-S1 laminectomy (removal of the back of vertebrae to decompress the spinal cord and/or nerves) on 21 May 2008 for central spinal stenosis (narrowing of the main central canal that protects the spinal cord).   Functional lumbar spine X-rays dated 3 July 2008 demonstrated post-surgical changes from the prior laminectomy at L4 and L5 levels and subtle narrowing of the L5-S1 intervertebral disc space.  X-rays dated 5 August 2008 demonstrated the prior L5 laminectomy, otherwise the spine was unremarkable in appearance.  Postoperatively, the CI required the use of Mobic (meloxicam, a nonsteroidal anti-inflammatory drug and Ultram (tramadol, an opioid-like medication).  However, it was felt the CI was not the best candidate for remote duty stations, sea duty, or deployment since it was necessary he should be stable for 6-12 months before being considered for those duties; however, he was found not fit for sea duty.

The 9 November 2008 MEB NARSUM examination, 9 months prior to separation, noted complaints of chronic low back pain and was still in the recovery phase post-surgery.  The examiner deferred to orthopedics to comment on the expected length and degree of recovery.  No physical examination was performed.

During the 1 December 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported “back spasm at night/tramadol helps.” Physical examination noted the back assessment was “within normal limits,” except for a positive straight leg raise (to determine nerve root irritation) to 20 degrees.  An addendum to the report of the MEB, dated 17 February 2009, 6 months prior to separation, reported complaints of back pain, rated 2-6/10 (10 being the worst pain), which caused difficulty with prolonged standing, walking for distances, or performing his military duties.  The pain was relieved with tramadol and an analgesic (acetaminophen).  Physical examination revealed a range of motion (ROM) of forward flexion at 85 degrees (normal 90) and the combined ROM at 215 degrees (normal 240).  Muscle strength of the lower extremities was normal.

At the 10 September 2009 VA Compensation and Pension evaluation, performed 1 month after separation, the CI reported constant low back pain that travelled to the right leg and foot and occasionally travelled to the left hip, which caused difficulty with prolonged standing or walking.  The pain was relieved by rest and tramadol.  He also noted weakness of the spine, leg, and foot, and indicated he suffered from symptoms of spinal stiffness, spasms, decreased motion, paresthesias (abnormal sensation, usually tingling or prickling) and numbness; however, he denied any bowel or bladder dysfunction or any incapacitating episodes.  Physical examination showed no evidence of radiating pain on movement and no muscle spasm or tenderness of the back.  There was no guarding of movement and no evident weakness.  Provocative testing for nerve root impingement was negative bilaterally.  An initial flexion was 90 degrees; however, ROM measurements after repetitive motion were flexion 45 degrees and the combined ROM 130 degrees, limited by pain.  The spine showed normal curvature and symmetry.  Neurologic evaluation was unremarkable with no signs of a lumbar intervertebral disc syndrome with chronic and permanent nerve root involvement.  Lumbar spine X-rays finding were within normal limits.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 20%, coded 5237 (lumbosacral strain).  The Navy PEB also listed spinal central canal stenosis as a related Category II condition (a condition that contributed to the primary unfitting condition but was not separately ratable).  The impairment from the central canal stenosis was properly subsumed under the rating for the chronic low back pain IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The VA also rated the low back condition 20%, coded 5239 (spondylolisthesis or segmental instability), based on the VA C&P examination 1 month after separation, citing limitation of forward flexion.  

The panel members agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) as reported on the VA examination, which was closer to separation than the MEB NARSUM addendum; however, it is not clear whether to CI had an accident or injury or it was due to postoperative changes such as  deep scarring that developed in the interim to account for the significant decrement in the ROM during repetition during the VA examination from an initial 90 degrees for flexion to 45 degrees.  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).  The next higher VASRD rating of 40% specifies criteria of “forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine,” which was not supported by the evidence of record, so a higher rating is not justified.  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 chronic low back pain s/p laminectomy and discectomy condition.  

PANEL 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.  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 20150805, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN

		
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