RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE: pd-2016-01159
BRANCH OF SERVICE:  air force	SEPARATION DATE:  20040130

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Aerospace Maintenance Journeyman, medically separated for “spondylitic spondylolistesis L5-S1 status post fusion” with a disability rating of 10%.  

CI CONTENTION:  Requested review of 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 - 20031209	VARD - 20041004	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Spondylitic Spondylolistesis L5-S1	5299-5242	10%	Postoperative L5-S1 Fusion	5237	20%	20040624	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:

Spondylitic Spondylolistesis L5-S1.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in February 2002 while pulling off an aircraft panel.  He underwent an L5-S1 fusion on 27 May 2003 but continued to experience low back pain with lifting and bending.  The 14 August 2003 physical therapy (PT) evaluation, 6 months prior to separation, noted CI complaints of increased lumbar pain.  Physical examination showed a normal gait and back tenderness.  Range of motion (ROM) was flexion to 65 degrees (normal 90) and extension to 10 degrees without other ROMs recorded.  
At the 3 November 2003 MEB NARSUM examination, 3 months before separation, physical examination revealed flexion and extension restriction with painful motion.  Gait, contour, tenderness, and muscle spasm were not addressed.  A civilian back and joint evaluation on 1 March 2004 noted the CI was doing fairly well overall with “good and bad back-pain days.”  Physical examination showed ROM was “good” but painful motion, gait, contour, tenderness, and muscle spasm were not addressed.  

During the 24 June 2004 VA Compensation and Pension (C&P) evaluation, 5 months after separation, the CI reported severe back pain twice weekly after lifting or twisting.  He was not able to run, and could only walk for 20 minutes, sit for 30 minutes, and stand for 1 hour.  Physical examination revealed a normal gait, the ability to heel-toe walk without difficulty, and a flattened lumbar spine without spinal tenderness or muscle spasm.  ROM was flexion to 70 degrees (normal 90) (recorded as 68 degrees with pain at 40 degrees) and combined ROM was 205 degrees (normal 240); painful motion was present.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5239 (spondylolisthesis or segmental instability).  The VA rated the back condition 20%, coded 5237 (lumbosacral strain), based on the C&P evaluation, citing limitation of flexion.  Panel members agreed the PT evaluation supported a 10% rating for thoracolumbar forward flexion greater than 60 degrees but not greater than 85 degrees; and although there were no specific measured ROM limitations reported by the NARSUM, the “restriction” of ROM also supported a 10% rating as any 5 degree decrease in any plane of motion would indicate combined ROM of less than 240 degrees.  Additionally, both the NARSUM and civilian spine examinations most proximate to separation supported a 10% rating for the presence of painful motion.  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.  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 of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded 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 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 20160928 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-01159.

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,

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings