RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXXXXXXX	CASE: PD-2015-02251
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20050121

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Aircraft Electrical Repairer, medically separated for “multilevel degenerative disc and joint disease of the cervical spine” with a disability rating of 10%.

CI CONTENTION:   The condition “causes me great hardship.”   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 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 - 20041007		VARD - 20050316	
Condition	Code	Rating		Condition	Code	Rating	Exam	
Multilevel Degenerative Disc and Joint Disease of the Cervical Spine	5242	10%		Cervical Degenerative Disc Disease	5242	10%	20041025	
				Decreased Sensation in Left Arm	8599-8515	10%		
COMBINED RATING: 10%		COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:

Cervical Spine Degenerative Disc and Joint Disease. According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a history of chronic neck pain without any specific injury that included (non-dominant) left upper extremity (LUE) radicular symptoms exacerbated during a 2003-2004 deployment to Iraq. Magnetic resonance imaging (MRI) demonstrated multilevel degenerative disc disease (DDD) from C2-7, with diffuse “very mild” stenosis and “very mild” bilateral foraminal narrowing confined  to  C4-6.    Multiple  STR  clinical  entries  documented  normal  neurological  findings

(including 5/5 strength), with none to the contrary. Neurosurgery opined that surgery was not indicated. There was STR documentation of grossly normal range of motion (ROM) and no entries that indicated more severe limitation. There was no STR documentation of abnormal spinal curvature or incapacitating episodes.

The 17 September 2004 NARSUM examination, 4 months prior to separation, documented “significant pain” with LUE radiation and sensory symptoms that interfered with lifting, running, and load-bearing. The physical examination recorded tenderness and spasm, “full” ROM with “minor” painful motion, and normal neurological findings (5/5 strength, intact sensation, symmetric reflexes). Formal physical therapy ROM measurements for the MEB (2 weeks after the NARSUM) were flexion to 45 degrees (normal) with a combined ROM of 230 degrees (normal 340), specifying painful motion.

The 25 October 2004 VA Compensation and Pension (C&P) examination, 3 months prior to separation, documented constant “moderate” neck pain with exacerbations to 10/10, associated with LUE radicular pain and sensory symptoms (no subjective weakness), and aggravated by lifting and prolonged sitting. The physical examination recorded tenderness and a normal spinal contour without note of spasm. The examiner assessed 4/5 proximal LUE strength and described a mild (light touch only) diffuse non-dermatomal LUE sensory deficit. Measured ROM by the VA on 7 October 2004, showed a flexion of 45 degrees with a combined ROM of 250 degrees, specifying painful motion.

The panel directed attention to its rating recommendation based on the above evidence. The PEB’s 10% rating under code 5242 (degenerative arthritis of the spine) specified the absence of neurological deficits and was consistent with VASRD §4.71a criteria for the service ROM evidence and other ratable findings. The VA’s 10% rating under the same code cited the C&P and VA ROM evidence as satisfying the §4.71a 10% criterion of “combined [ROM] ... greater than 170 degrees but not greater than 335 degrees.” There was no ROM evidence supporting a rating higher than 10%, no evidence for abnormal spinal contour to support a 20% rating, and no documentation of incapacitating episodes that would provide for a higher rating under that formula.

The VA conferred an additional 10% rating for the LUE radiculopathy under code 8599-8515 (analogous to partial paralysis of the median nerve) for “mild” impairment. The panel considered if service rating was also justified for the radiculopathy. The presence of functional impairment with a direct impact on fitness is the key determinant in the panel’s decision to recommend any condition for rating as additionally unfitting. While the CI may have suffered additional pain from nerve involvement, this is subsumed under the §4.71a general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).” The only objective neurological deficits in evidence were those assessed by the C&P examiner (as above), and these were not corroborated by the service evidence from multiple examiners including the NARSUM and a neurosurgical consultant. Members thus agreed that the preponderance of evidence did not support the consistent presence of neurological impairment that would unacceptably impact military occupation-specific activities, and that an additional service 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 panel concluded there was insufficient cause to recommend a change in the PEB adjudication of the lumbar spine condition.

BOARD FINDINGS: In the matter of the multilevel degenerative disc and joint disease of the cervical spine 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 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 20150819, w/attachments Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record

AR20170012859 , 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