RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00490
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20021118

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Security Forces Journeyman, medically separated for “low back pain” with a disability rating of 20%.

CI CONTENTION:  The CI makes no specific contentions.  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 - 20020924	VARD - 20130909	
Condition	Code	Rating	Condition	Code	Rating	Exam	
 Chronic Lower Back Pain	5295	20%	Lumbar L2-3 Degenerative Disc Disease S/P Microdisectomy	5003-5242	10%	20130909	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Lower 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 January 1996 following a motor vehicle accident (MVA) for which he initially received non-surgical conservative treatment.  From 1996 through 2001, the CI re-injured his low back several times and eventually underwent a surgical lumbar discectomy on 21 February 2002.  At the time of the neurosurgical clinic appointment on 8 July 2002, the CI reported persistent bilateral lumbar pain as well as thigh numbness.  His physical examination (PE) revealed the ability “to walk well on his heels and toes.”  His knee reflexes were equal and normal.  There was a “report of decreased sensation in his thighs.”  There was no VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 20%, coded 5295 (lumbosacral strain), citing pain medication requirement and functional loss.  Utilizing current spine rules, the VA rated the lumbar L2-3 degenerative disc disease status post microdisectomy 10% analogously coded 5242 (degenerative arthritis) and radiculopathy, left lower extremity an additional 10% coded 8626 (neuritis of the anterior crural nerve) based upon a multi-year remote from separation examination.  
	
The Veterans Administration Schedule for Rating Disabilities (VASRD) coding and rating standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards on 26 September 2003.  The Service separation date of November 2002 resulted in the PEB rating the low back condition according to the interim spine rules.  The VA rated the condition according to the new spine rules that specify rating thresholds in degrees of range of motion (ROM) impairment.  The older standards for rating based on ROM impairment were subject to the rater’s opinion regarding degree of severity, hence the PEB’s rating of 20% based on medication use and the CI’s level of functionality.  There was no evidence of listing of the whole spine to opposite side, positive Goldthwaite's sign, marked limitation of forward bending in standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion to assign a higher rating than 20% coded as 5295 under the VASRD interim spinal rules.  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 20120901, 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-2016-00490.

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.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have 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.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings