RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02382
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090727

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Electrical Systems Journeyman, medically separated for “chronic back pain” with a disability rating of 10%.

CI CONTENTION:  The CI contends that his back condition should have been rated at well above the 10% based on the severity of the condition and how it has negatively impacted his life.  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 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 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 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 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 - 20090326	VARD 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5243	10%	No VARD in evidence	 	 	  	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in May 2007 without any specific injury or trauma.  Magnetic resonance imaging (MRI) on 30 June 2008 showed degenerative disc disease (DDD) from T4-T9 “without abnormal cord signal.”  Evaluation by neurosurgery in July 2008 did not recommend surgical intervention.  X-rays taken on 2 February 2009 indicated a mild disc height loss at L5-S1 (the loss was not quantified), otherwise they showed a normal lumbar spine.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic thoracic back pain” for PEB adjudication.  The 4 February 2009 MEB NARSUM examination, 6 months prior to separation, noted complaints of back pain of 3 to 4 out of 10 on the pain scale.  His pain worsened with heavy lifting or increased activity.  He denied bowel or bladder dysfunction, radiation of pain, and weakness in lower extremities.  Physical examination showed that he had “palpable spasm and ropiness in his thoracic paraspinal muscles, but they did not cause abnormal spinal contour or gait.  There was no tenderness and he had normal range of motion without pain.  He had normal motor strength, reflexes and sensation and tests for radiculopathy were negative.  There were no VA Compensation and Pension (C&P) evaluations or VA ratings to analyze.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5243 (intervertebral disc syndrome).  Although there was insufficient limitation of motion to support a minimum rating, the panel agreed a 10% rating was justified for the presence of spasm.  However, the muscle spasm was not severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  Although there was a non-quantifiable loss in disc height, the maximum rating for loss of disc height is only 10% and so would not benefit the CI.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  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 back condition.  

BOARD FINDINGS:  In the matter of the back 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, w/atchs
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-2015-02382.

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.  The Board recommended no re-characterization or modification of your separation.

I 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.  I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings