RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02561
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20061030

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an mobilized National Guard O1, Signal Officer, medically separated for “chronic low back pain” with a disability rating of 10%.

CI CONTENTION:  The CI made a contention for worsening degenerative disc disease of the spine, and additional conditions; cervical spine and headaches.  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 conditions at the time of separation.  The panel has neither the role nor the authority to compensate for 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 - 20050701	VARD - 20060411	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Degenerative Disk Disease of the Lumbosacral Spine	5242	10%	20051222	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in November 1999 after an injury during an airborne operation.  The CI separated from active duty in October 2000, and the VA denied service connection.  The CI had an Emergency Room visit in January 2003 for low back pain after lifting a heavy box, which was treated with Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever) and Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID).  At a follow-up visit the examiner noted the CI had magnetic resonance imaging (MRI) of the spine in the prior year, which showed a herniated nucleus pulposus (HNP) at L4-L5 and L5-S1.  At the CI’s request, chiropractic therapy was instituted.  An MRI on 13 February 2003 demonstrated a slightly larger central disc protrusion at L5-S1, which touched the right S1 and mildly displaced the left S1 root.  The CI again complained of low back pain in October 2003 for a week, which was treated with Percocet and a profile.  In November 2003 the CI was evaluated for activation pending deployment and reported her pain was “getting worse.”  Examination revealed a normal gait, range of motion (ROM) measurements showed a normal flexion 90 degrees, extension of 20 degrees (normal 30), and good muscle strength with an unremarkable neurologic evaluation.  An orthopedic consultant noted the MRI showed an annular tear at L4-L5 and a disk protrusion at L5-S1.  A P3 profile was recommended.    

ROM measurements in February 2004 showed a flexion of 85 degrees and extension of 10 degrees.  Lumbar spine X-rays in February 2004 demonstrated findings suggestive of muscle spasm and mild degenerative disc disease changes at L4-5 and L5-S1.  An MRI in March 2004 showed an unchanged small annular tear at the L4-5 level with a small posterior disc protrusion and marked improvement of the disc protrusion at L5-S1; and, the mass effect on S1 nerve root on the left was no longer present.  Computerized tomography (CT) with a lumbar myelogram in July 2004 demonstrated a small left posterior disc protrusion at L4-L5 with mild narrowing of the left lateral recess and minimal retrolisthesis (a vertebra sliding backward over the one below it) and broad-based posterior disc protrusion without mass effect at L5-S1.  The CI received a steroid/anesthetic injection for right sacroiliac joint pain, which was not diagnostic as a source of her pain.  She then underwent right L4, L5, and S1 medial branch blocks with bupivacaine, an anesthetic.  Despite a subsequent radiofrequency ablation of the medial branches, she did not have resolution of her low back pain, which a pain management specialist felt was clearly mechanical in nature and was localized to the iliolumbar angle bilaterally without any neurologic symptoms or radicular pain.  The pain management specialist felt the pain could be managed with Celebrex (celecoxib, an NSAID) and Ultram (tramadol, an opioid-like medication) as needed.  There was no surgical indication in the absence of radicular features.  

At an orthopedic clinic appointment on 10 January 2005, for a specialty care consult for the MEB, the CI reported “I have low back pain,” with constant pain in the left buttock and on rare occasions radiation down her left leg.  Physical examination showed a normal gait and a full ROM of her lumbosacral spine.  A straight leg raise test (to determine nerve root irritation) was negative.  There was some tenderness to the right side of the L5-S1 disc space.  Neurologic evaluation was unremarkable.  The examiner diagnosed the condition as severe degenerative disc disease at L4-5 and L5-S1 and recommended separation from military service.  A lumbar spine series in March 2005 demonstrated minimal intervertebral disc space narrowing.  Lumbar ROM measurements on 9 March 2005 by a physical therapist showed three repetitions with flexion of 60, 61, and 62 degrees limited by pain; and extension 20, 21, and 22 degrees; and a combined ROM of 160 degrees (normal 240).  

During the 5 April 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 19 months prior to separation, the CI reported severe, chronic lower back pain with aggravation within the past year.  Physical examination showed minimal generalized tenderness to palpation about the lower lumbar and bilateral sacroiliac joint areas.  There was no paravertebral tenderness to palpation.  The 5 April 2005 MEB NARSUM examination, 4 months prior to separation, noted complaints of “degenerative disc disease and chronic low back pain.”  Physical examination showed the spine was inline without step offs or deviations.  There was minimal tenderness, negative straight leg raise testing, normal reflexes, and normal strength, and sensation was intact.  

At the 22 December 2005 VA Compensation and Pension (C&P) evaluation, performed 10 months after separation, the CI reported low back pain with no radiation to the buttocks or to the legs.  Physical examination showed a normal posture and gait.  The CI used no assistive devices or a back brace. ROM measurements showed a normal flexion of 90 degrees with pain, and a normal combined ROM of 240 degrees.  There was tenderness at the L5 level paraspinal area, but no effusion, no erythematous change, no muscle atrophy, and no muscle spasms.  The CI’s lower back motion was not limited by pain or weakness.  Reflexes and strength were normal and there was no radiculopathy or episodes of incapacitation in the prior 12 months.    

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing limitation of motion.  The VA also rated the back condition 10% coded 5242 (degenerative arthritis of the spine), citing tenderness on examination.   Although there was insufficient limitation of motion to support a minimum rating, the panel agreed a 10% rating was justified for the presence of painful motion and tenderness.  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.  

However, the panel noted that the limitation of thoracolumbar motion recorded by physical therapy for the MEB NARSUM examination met the threshold for a 20% rating when using VASRD rules despite the fact that the CI could flex beyond 60 degrees to 62 degrees.  Furthermore, the combined ROM using the VASRD rules was 160 degrees, which does support a 20% rating.  However, examinations in evidence performed by physical medicine, orthopedics, specialty care, and VA C&P all showed normal flexion or full ROM.  

The VA examination ROM measurements were 4 months after separation, they were more proximate than the physical therapy measurements 5 months before separation thereby affording a higher probative value to the VA examination.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula.  Therefore, 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 condition. 

BOARD 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 were 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 20150602, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170013322, XXXXXXXXXXXXXXXXXXX. 

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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. 

A copy of this decision has been provided to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,					      
						      					
Enclosure