RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00410
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080909

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Patriot Fire Control Operator, medically separated for “chronic neck pain” with a disability rating of 20%.

CI CONTENTION:  The CI contends that the VA assigned a disability rating of 30% for cervical spine spondylosis with discogenic disease, 30% for cephalgia, tension type, 30% for mood disorder due to general medical condition, and 10% for chronic maxillary sinusitis, for a combined disability rating of 70%.  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 - 20080701	VARD - 20090416	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain 	5299-5237 	20%	Cervical Spine Spondylosis with Discogenic Disease	5299-5239	30%	20090318	
Occipital Neuralgia	Not Separately Ratable (Pyramiding)	Cephalgia, Tension Type Associated with Cervical Spine Condition	8199-8100	30%	20090318	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Neck Pain Diagnosis.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck condition began in October 2007 after 2 months of training during which the CI was wearing his Kevlar frequently.  No neck or head trauma reported.  The pain was noted to be in the posterior cervical spine at the base of the neck and radiated to the posterior skull when exacerbated.  MRI of the C-spine demonstrated “minimal to mild multilevel degenerative disc disease worse at C3-4 and C6-7” and “mild left facet joint hypertrophy minimally narrowing the left neural foramina at C4-C5.”  Surgical intervention was not offered.  On several occasions, he approached his primary care provider to receive restriction to quarters (for both neck pain and headaches.)  The neurological examination was normal.

The 22 April 2008 MEB NARSUM examination, 5 months prior to separation, noted complaints of constant moderate to severe pain located in the posterior cervical spine exacerbated by strenuous activity.  The CI reported that he was unable to wear required military equipment, including his helmet or vest or participate in any physical training.  The CI was treated with multiple analgesics including narcotics and epidural steroid injections without relief.  The examiner also noted the pain had been stable for months.  Physical examination showed “tenderness on bilateral occiput overlying greater occipital nerves.”  Neck range of motion (ROM) was reported as full with pain on flexion, extension and rotation to either side.  

The 6 June 2008 physical therapy examination, 3 months prior to separation, showed forward flexion of 20 degrees (normal 45) after repetition and total combined thoracolumbar ROM of 130 degrees (normal 340) after repetition.  ROM was limited by pain but not by fatigue, lack of endurance, incoordination, and weakness.  Muscle spasm and guarding were noted and he had increased thoracic kyphosis with the beginning of a “dowager’s hump.”  There was no muscle atrophy or deformity.  The 19 June 2008 commander’s statement indicated that the CI was not performing any duties in the unit or in his MOS.  The 20 June 2008 MEB NARSUM Addendum noted no change in findings from the original NARSUM.  

Primary care follow-ups in June and July 2008 noted the use of cervical traction and a TENS unit to treat the chronic neck pain.  He was also using an anxiolytic medication at bedtime for muscle spasms in the neck.  He reported constant, daily neck pain with severe episode 3-4 times per week, so bad he would start vomiting.  He reported he could only sleep 3-4 hours per night.   The 1 July 2008 primary care note indicated a synthetic narcotic agent did not help the neck pain on the right and pain was increased when turning the head to the right. Pain was relieved to the left by immobilizing the head.  The evaluation of the head was normal and there were no neurological symptoms. 

At the 18 March 2009 VA Compensation and Pension (C&P) evaluation, 6 months after separation, the CI reported some degree of pain all the time rated 3/10 in intensity.  Neck pain was aggravated by repetitive activity (turning his head and walking) and rated at 7-9/10.  Pain management included three epidural injections, TENS as need, OxyContin (narcotic pain medication) and Naproxen (non-narcotic pain medication).  He received occipital nerve blocks for the treatment of occipital neuralgia.  Pain was generally in the muscles of the neck down to about the middle of the shoulder blades in a band along the spine.  He tried to limit movement of his neck, especially while driving and looking up and down.  He propped his head and neck with a pillow.  He was a full time student and lived with his family.  He was able to perform activities of daily living.  He was able to walk 1/2-mile before taking a break due to neck pain and he could go and down 1-2 flights of stairs without difficulty.  Upper extremity function was normal and he had no problems with loss of balance or falls.  Physical examination showed normal gait.  Muscle mass, tone, and strength of all extremities was 5/5 bilaterally.  No fatigue or lack of endurance was reported.  Mild tenderness along the spinous processes and bilateral paraspinal muscles was noted without overt spasm.  Pain was noted during the examination by facial grimacing and statement; it was rated at 4/10 increasing to 6/10 after repetitive range of motion.  Active forward flexion was 25 degrees, but decreased to 10 degrees after repetitive motion and combined ROM was 160 degrees, but decreased to 95 degrees after repetitive motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 20%, coded 5299-5237 (analogous to cervical strain), citing forward flexion functionally limited to 20 degrees.  The VA rated the neck condition 30%, coded 8199-8100 (analogous to migraine headaches, with characteristic prostrating headaches occurring once per month over several months ), and based on the C&P examination 6 months after separation, citing forward flexion of the cervical spine of 15 degrees or less.  The panel agreed that a 20% rating, was justified for limitation of flexion greater than 15 degrees but not greater than 30 degrees reported on the physical therapy examination most proximal to date of separation.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes, which would provide for a higher rating under that formula.

Contended PEB Condition:  Occipital Neuralgia.  According to the STR and MEB NARSUM, the CI reported headaches in the occipital region, exacerbated by strenuous activity in October 2007.  The pain was unrelieved by muscle relaxers, barbiturates, Imitrex (for migraines), non-steroidal anti-inflammatory agents (NSAIDS) or synthetic painkillers.  There was no pain in any other part of his head, no photophobia, phonophobia, nausea, visual aura, or limb symptoms to include paresthesias, weakness or numbness.  Initially, doctors diagnosed his headaches as tension-type headaches or headache syndrome.  In February 2008, the neurologist diagnosed the headaches as occipital neuralgia.  Neuroimaging was as described above.  A diagnosis of left occipital neuralgia was rendered.  Occipital nerve block brought only temporary relief.  

At the 11 April 2008 primary care clinic visit, the examiner noted that the CI’s First Sergeant was very concerned about the CI’s ongoing headaches and inability to attend class.  The CI had had 18 days of quarters since 19 February 2008 (19 & 27 February, 7, 13, 18, 25, 27, 31 March, and 4 & 7 April) some for 48 hours.  Additionally, the STR showed that the CI was placed on quarters on 21 May 2008 and 2 June 2008 for headaches.

At the 18 March 2009 VA Compensation and Pension (C&P) evaluation, 6 months after separation, the CI reported the headaches began in October 2007 along with the neck pain and were located in the occipital area of the head.  He denied an aura, photophobia, phonophobia, nausea, and vomiting.  He reported different degrees of headaches and had a daily headache in the background, four times per week and a more severe headache 2-3 times per week.  Sometimes the headaches cycled at 20-minute intervals (20 minutes with and 20 minutes without).  With a severe headache, he was unable to function.  He used a neck roll pillow as noted above.  Diagnoses of spondylosis and headaches, tension type, due to degenerative changes of the cervical spine with episodic incapacitation were rendered.  The examiner noted the headaches were previously diagnosed as occipital neuralgia.  

Although occipital neuralgia was not profiled, it was forwarded to the PEB, along with chronic neck pain for adjudication.  The PEB subsumed occipital neuralgia under the chronic neck pain diagnosis, noting that rating was not possible due to VASRD 4.14 pyramiding (avoidance of evaluation of the same disability under various diagnoses).

Although there are two diagnoses, “chronic neck pain” and “occipital neuralgia,” the panel concluded the overall disability was the same, and that both conditions have a disability as a result of pain versus a disability as a result of limitation of motion.  Therefore, the primary disabling factor was pain, which was manifest in both conditions.  IAW VASRD §4.7, “where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating.  Otherwise, the lower rating will be assigned.”  Therefore, the panel evaluated the diagnoses under their applicable VASRD codes.  Although there was limitation of motion of the cervical spine that met the criteria for a 20% rating under the General Rating Formula for Disease and Injuries of the Spine, the evaluation of occipital neuralgia under an analogous 8100 code (migraine), meets the criteria for a 30% rating.  This rating requires characteristic prostrating attacks occurring on an average of once a month over the last several months.  The panel agreed that the CI’s disability due to pain, IAW VASRD §4.7, should be rated at 30%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the occipital neuralgia condition, coded 8199-8100. 

BOARD FINDINGS:  In the matter of the contended occipital neuralgia condition, the panel unanimously agrees that it was unfitting and recommends a disability rating of 30%, coded 8199-8100 IAW VASRD §4.7, §4.14 and §4.124a.  In the matter of the neck condition the panel unanimously recommends that it be subsumed in the rating for occipital neuralgia to avoid pyramiding IAW VASRD §4.14.  There were no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Occipital Neuralgia	8199-8100	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160621, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170015553, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,					      
Enclosure