RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX  	CASE:  PD-2016-00666
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20040920

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Air National Guard E6, Aerospace Propulsion Craftsman, medically separated for “cervical myelopathy secondary to cervical spondylosis, degenerative disc disease and severe spinal stenosis status post diskectomy and C4-C7 fusion, EPTS [existed prior to service] with service aggravation” with a disability rating of 20%.

CI CONTENTION:  The CI requested review of tinnitus condition.   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 - 20040802	VARD - 20050411	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Myelopathy Secondary to Cervical Spondylosis…	5243-5241	20%	Cervical Spine Condition*	5237	NSC	20031216	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	
*VARD dated 20060306 rated cervical condition at 20% and left upper extremity at 30% effective date of separation

ANALYSIS SUMMARY:  

Cervical Myelopathy Secondary to Cervical Spondylosis, Degenerative Disc Disease (DDD) and Spinal Stenosis Status Post Diskectomy and C4-C7 Fusion, EPTS with Service Aggravation.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-dominant CI experienced left shoulder pain while doing push-ups for a 6 December 2003 physical fitness test, and received an initial line of duty (LOD) determination on 7 December 2003 for his injury.  At an orthopedics evaluation on 16 December 2003, the CI stated that while doing push-ups, he felt “something pop” between his neck and left shoulder, with secondary pain down the left arm.  The examiner noted the CI injured his neck in high school during wrestling and left shoulder in a dirt bike accident in the early 1980s.  On examination, the left shoulder had near full range of motion (ROM), but neck ROM was restricted and aggravated his pain.  X-rays showed an old, healed, humeral head fracture and significant cervical degenerative joint disease (DJD) and DDD from C3-C7.  The specialist opined that current symptoms were a flare of the pre-existing disease and not secondary to an injury while doing push-ups.  An MRI on 30 December 2003 confirmed the multilevel DJD and DDD and also revealed severe spinal stenosis at C5-6 and C6-7.  The CI subsequently saw another orthopedic surgeon for a second opinion on 8 January 2004, and surgery was recommended.  A revised LOD was issued on 27 January 2004 for cervical spondylosis with myelopathy (injury to the spinal cord).  

The CI underwent a diskectomy and C4-7 vertebral fusion on 2 February 2004, and experienced nearly full resolution of weakness and pain symptoms 10 days later.  He was referred to physical therapy (PT) for rehabilitation and showed improved ROM and function.  On 18 March 2004, the orthopedic surgeon noted normal strength and sensation, but incomplete healing at C6-7.  At a 27 April 2004 PT visit, the CI was thought to have plateaued in his recovery, with his strength about 50% of normal.  However, 2 days later in orthopedics, the examiner documented normal strength and sensation.  At a 29 July 2004 orthopedic follow-up, some residual weakness was noted in the left muscles innervated by C5 and C6, but sensation remained normal with “reasonable” ROM.

The 7 July 2004 MEB NARSUM examination, 2 months prior to separation, recorded complaints of continued neck pain.  The CI was unable to wear combat head gear, a flak vest or chemical ensemble.  It was noted that in prior post-operative follow-ups, neck flexion had been 18 degrees and extension 35 degrees with normal strength.  The physical examination showed the CI had “reduced cervical flexion” and extension past 35 degrees caused tingling into his left arm.  Bilateral upper extremity muscle strength was 5/5 with sensation intact.  

A 25 January 2005 VA Compensation and Pension (C&P) examination was not in evidence.  When reevaluated in orthopedics on 27 January 2005, almost 12 months after surgery and 4 months after separation, the CI reported some residual weakness in the left upper extremity, but that he was “working out a lot.”  On examination, he demonstrated generalized upper extremity weakness which was not further specified.  Bilateral arm circumference at mid-level was 38 cm (normal with no atrophy); sensation remained intact. 

On 22 April 2005, the treating orthopedist noted the CI’s myelopathy was due to the push-up injury in December 2003; and although there was pre-existing disease, he had not been myelopathic prior to this incident.  During a 3 May 2005 C&P hand examination, the CI’s left hand and arm were weaker than the right (estimated to be  four times stronger), but atrophy was not recorded.  Even though he was right-handed, the examiner noted he was “basically ambidextrous” and documented the presence of “intrinsic hand disease” which could not be separated from cervical disease in terms of contribution to weakness.  Another hand evaluation by a different specialist on 16 June 2005, 9 months after separation, detailed a left-hand crush injury in September 1990 as well as surgery on the left 4th finger in 2001 and a residual Dupuytren’s contracture in both 4th fingers.  The CI reported pain and dexterity loss since the 1990 injury, but denied grip problems until the neck injury.  On examination, reduced neck ROM (not quantified), left upper extremity/shoulder girdle atrophy, and decreased sensation were recorded.  The specialist opined the weakness was more likely due to the cervical rather than the crush injury.  A 22 February 2006 X-ray showed advanced shoulder joint degenerative arthritis.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the cervical myelopathy condition 20%, coded 5243-5241 (intervertebral disc syndrome/spinal fusion).  While it considered the condition to have existed prior to service, the level of service aggravation could not be ascertained, and therefore 0% was deducted from the rating.  Although the PEB cited “cervical myelopathy” as the unfitting condition, members noted the 20% rating was appropriate for the limitation of motion using code 5241, and that there is no specific VASRD code for myelopathy.  The VA initially did not service-connect the cervical condition and radiculopathy based on the 16 December 2003 orthopedic assessment, but following a Decision Review Officer (DRO) evaluation, it rated the cervical condition 20%, coded 5242-5241 (degenerative arthritis of the spine/spinal fusion), citing limitation of motion.  The VA also rated the radiculopathy condition 30%, coded 8599-8510 (upper radicular group, 5th and 6th cervical nerves,) citing significant loss of strength (at the moderate level).  This rating was based on VA examinations on 25 January 2005, 16 June 2005, and 22 February 2006 as well as a letter from the treating physician dated 22 April 2005.  

The panel first considered the presence of an unfitting myelopathy at separation.  Five months prior to separation, PT documented a 50% loss of strength, but orthopedics recorded a normal motor examination 2 days later.  The NARSUM also noted normal strength and sensation 2 months prior to separation.  In orthopedics 3 weeks later, some residual weakness was observed in C5 and C6 innervated muscles on the left.  Four months after separation, generalized left upper extremity weakness was documented, but a measurement for atrophy was negative.  The panel observed that examinations at 8 and 9 months after separation showed more impairment with some atrophy, but that the CI had sustained injuries to both the hand and shoulder independent of the neck condition.  Additionally, left shoulder X-rays showed significant arthritis.  Members noted one examiner opined that the impairment was primarily from the neck while another determined it could not be attributed to a specific injury or condition.  The panel concluded the contribution to the left upper extremity impairment from a myelopathy could not be determined from the evidence.  Multiple examinations showed normal function, while others were inconsistent.  Members agreed a non-compensable rating is supported by the evidence for the cervical myelopathy condition.  

The panel observed that the degenerative changes of the spine were not determined to be separately unfitting by the PEB, and since not specifically contended by the CI, this condition is outside the panel’s scope of review.  Members did observe that the MEB determined the cervical spondylosis with myelopathy to be medically unacceptable and further noted this diagnosis warranted both the rating and coding options chosen by the PEB.  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 neck condition.  

BOARD FINDINGS:  In the matter of the cervical condition and IAW VASRD §4.71a and 4.124a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends 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 20160912, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

SAF/MRB

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-00666.

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