RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02383
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20051130

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Ground Radio Intermediate Repairer, medically separated for “chronic lumbar degenerative disk disease [DDD] at L5-S1 status post anterior interbody lumbar fusion,” with a disability rating of 20%.

CI CONTENTION:  The CI’s condition continues to worsen and negatively affects daily activities.  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 - 20050922	VARD - 20060519	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Lumbar DDD at L5-S 1 Status Post Anterior Interbody Lumbar Fusion	5241	20%	Herniated Nucleus Pulposus, Lumbar Spine Status Post
Micro Discectomy and Anterior Fusion	5241	20%	20051102	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Lumbar Degenerative Disk Disease.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a previous history of a herniated disk without trauma and underwent surgery in September 2001 for a left LS-S1 microdiskectomy.  Following surgery the CI’s condition initially improved, but gradually deteriorated and the CI underwent a second surgery on 14 March 2005 for an anterior lumbar interbody fusion.  Further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “low back pain with left S1 radiculopathy” and “degenerative disk disease at L5-S1” for PEB adjudication.  The MEB NARSUM examination on 1 June 2005, 6 months prior to separation, noted complaints of persistent pain when increasing physical activity, provoked by stairs, transitioning from sitting to standing, PFT exercises and lifting objects greater than 10 pounds.  Physical examination recorded the CI wearing a lumbosacral brace that he was able to place and remove with proficiency.  Examination further revealed a well-healed 5 cm left parasagittal incision with the CI able to heel and toe walk and perform ADLs without difficulty.  The examination made no mention of radicular symptoms or lumbar ranges of motion.  At the 2 November 2005 VA Compensation and Pension (C&P) evaluation, performed 4 weeks before separation, the CI reported twice a day, sharp, low back pain radiating down the left lower extremity on a pain scale of 7/10.  The CI reported the pain was brought on by bending or leaning over and he missed about 3 hours of work per week due to pain.  The CI denied any incapacitating episodes. He reported he could function without medication.  Physical examination showed evidence of limited and painful motion in all directions and radiating pain to the left lower extremity.  There was no evidence of sciatica.  Range of motion (ROM) testing of the thoracolumbar spine with a goniometer, recorded flexion to 50 degrees (90 normal), extension to 10 degrees (30 normal), right and left lateral flexion to 20 degrees (30 normal) and right and left rotation to 30 degrees (normal).  ROM was limited by pain, lack of endurance and fatigue after repetitive use.  The ROM was not limited by weakness or incoordination after repetitive use.  Gait was normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic lumbar degenerative disk disease 20%, coded 5241 (spinal fusion).  The VA also rated the lumbar degenerative disk disease 20% coded 5241, based on the C&P examination 4 weeks before separation, citing forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees.  The Board agreed a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees).  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS). Although there was radiating lower extremity pain. The evidence did not support an unfitting radiculopathy for additional rating.  The Board 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 Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic lumbar degenerative disk disease.  

BOARD FINDINGS:  In the matter of the chronic lumbar degenerative disk disease 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 20150919, with attachments
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
       (b) CORB ltr dtd 25 Apr 17

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, 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 USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC 
		- 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
	     				  	  Assistant General Counsel
						  (Manpower & Reserve Affairs)