RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2016-01041
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20040312

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E3, Seaman, medically separated for “chronic low back pain” with a disability rating of 10%.  

CI CONTENTION:  Review requested for back condition and additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the MEB, but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20031103	VARD - 20050213	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5295	10%	Minimal Disc Bulge with Chronic Strain, Lumbar Spine	5237	20%	20041021	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began on 14 January 2003 at the start of basic training when he awoke with a headache after a meningococcal vaccination, and later lost consciousness and injured his back after falling.  He was treated at the emergency room and stated that that while undergoing a spinal tap, he felt the physician ‘hit a nerve that sent a shock down my right leg and made me jump off the bed.’  An MRI on 8 February 2003 revealed early degenerative disc disease at L5-S1 with mild bulging annulus and very minimal focal and left central herniation at L5-S1 without nerve root compression; surgery was not recommended.  The CI underwent L5-S1 lumbar epidural steroid injections under fluoroscopic guidance and contrast confirmation on 26 February and 13 March 2003.  Electrodiagnostic studies on 30 July 2003 were negative for radiculopathy.  

The 25 August 2003 MEB NARSUM neurology examination, 7 months prior to separation, noted CI complaints of LBP with marked difficulty walking due to weakness and pain.  Physical findings were repeated from a 12 February 2003 evaluation, and revealed midline tenderness from L4-S1 and over the bilateral facets, sacroiliac joints and sciatic notches.  There was additional referred pain from provocative maneuvers, and bilateral straight leg raise (SLR) tests were positive at 90 degrees, with pain radiating into the respective posterior thighs.  Right knee deep tendon reflexes were absent and otherwise symmetrically decreased in the lower extremities.  The provider concluded there was “no ongoing neurological disease,” noting MRI evidence of minimal degenerative changes and no nerve root compression, as well as normal EMG (nerve conduction study) tests showing no nerve root or peripheral nerve causing the CI’s symptoms.  The physician further stated that, “aside from some local bruising,” there was no indication that the spinal tap “could have caused the marked pain and reported weakness,” and that it was very unlikely that the fall in February 2003 would have produced the minimal L5-S1 changes which were “chronic in nature.”  There were no thoracolumbar range of motion (ROM) measurements in evidence.  

Neurology evaluation on 22 September 2003 noted CI complaints of continuing back pain.  Physical examination revealed an antalgic gait and increased pain with heel-to-toe walking.  Lower extremity strength was normal except for slight decreased left ankle movement, and there was tenderness and increased pain with hip/leg maneuvers.  A psychiatrist’s examination the following day also noted an antalgic gait due to back pain, with normal strength throughout.  A chiropractor memo dated 11 October 2004, documented an abnormal gait with tenderness and spasm, bilateral lower extremity weakness, and only temporary relief after adjustments.  

At the 21 October 2004 VA Compensation and Pension (C&P) general, spine and neurological examinations, 6 months after separation, the CI reported constant dull LBP, rated at 6/10, that was more pronounced with prolonged sitting.   During the spine evaluation, he reported using a back brace, and that while activities of daily living were not affected, he could not sit for long periods at work.  There was no history of flare-ups or incapacitating episodes during the previous 12 months, and he was not taking any prescription medication.  Physical examination showed normal spine alignment without tilting or scoliosis, and no spasm.  Thoracolumbar ROM measurements showed flexion to 45 degrees (normal 90), with a combined ROM of 170 degrees (normal 240), with painful motion in all planes.  There was no evidence of incoordination, weakness or fatigability, no functional loss due to subject complaints of pain, and no neurological deficit in either lower extremity.  The general C&P examination the same day also documented an antalgic gait.  Lumbosacral spine X-rays were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, coded 5295 (sacroiliac injury and weakness).  The VA rated the low back condition 20%, coded 5237 (lumbar strain), based on the C&P examination, citing limitation of motion.  Members noted the PEB rating used older VASRD coding (5295), and that newer criteria were in effect prior to the PEB and the CI’s separation.  The current VASRD rating guidelines for the spine are based on limitation of thoracolumbar ROM expressed in degrees, as well as gait.  Although there was no ROM recorded in the STR, there were multiple evaluations documenting an abnormal gait due to guarding or spasm.  The panel agreed that a 20% rating, but no higher, was justified for muscle spasm or guarding severe enough to result in an abnormal gait, as reported on the neurology examination; and for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) as reported on the VA examination.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the LBP condition, coded 5237.  

BOARD FINDINGS:  In the matter of the chronic low back pain, the panel recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5237	20%	

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve A£fairs) COMMANDER, NAVY PERSONNEL COMMAND
Subj:	PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS Ref:	(a) DoDI 6040.44
(b)	PDBR ltr dtd 02 Oct 18 ICO XXXXXXXXXX

l.	Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (k) are approved.	The official records of the following individuals are to be corrected as follows:

a.	XXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from
10 percent) effective date of discharge.
3.	Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.