RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01212
BRANCH OF SERVICE:  AIR FORCE 	SEPARATION DATE:  20041102

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Aerospace Propulsion Jet Engine Journeyman, medically separated for “chronic low back pain secondary to tethered cord syndrome,” with a disability rating of 10%.   

CI CONTENTION:  His condition continues to worsen and negatively impact his daily activities.  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 - 20040909	VARD - 20051103	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain (LBP) Secondary to Tethered Cord Syndrome	5237	10%	Degenerative Disc Disease Lumbar Spine Status Post Laminectomy for Tethered Cord Syndrome	5010-5242	40%	20050919	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP) Secondary to Tethered Cord Syndrome.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI presented in July 2003 with gradually worsening LBP over several years with a recent exacerbation due to lifting.  He was eventually diagnosed with tethered cord syndrome (spinal cord held tight in the spinal canal, rather than being free to move-due to such things as malformations or thickened soft tissue leading to spinal cord stretching and neurological symptoms including lower extremity weakness, sensory deficits, bowel, bladder, and sexual dysfunction) and underwent partial lumbar laminectomy and section of the filum terminale (fibrous end of the spinal cord that continues below the lumbar nerves).  Following the surgery the CI had significant improvement in bladder and sexual function, but not much improvement in LBP or functional status.  He continued to report LBP and paresthesias of the left lower extremity (LE).  Physical therapy (PT) notes between 13 February and 21 September 2004 noted unchanging LBP with left LE pain and paresthesias.  Four PT visits documented ROM with a difficult to interpret stick diagram.  Two of these PT diagrams noted “decreased” ROM, the other two did not label the ROM as decreased, but the diagrams were all similar in appearance.  The 21 April 2004 physical therapy visit (with ROM diagram) noted decreased ROM and pain at end ROM.  From March 2004 to October 2004, there were ten emergency room and/or acute visits for LBP in record.  At seven visits the CI was placed on quarters and total duration of quarters documented in the record was 7 days and 3 of the 7 days were specifically indicated to be for bed rest.  

The 21 July 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of continued back pain despite PT.  The examiner referenced a February 2004 examination stating no paraspinal muscle spasms and slight swelling around the well-healed incision.  Strength was normal and sensation was intact in the lower extremities.  No ROM measurements were recorded. 

At the 19 September 2005 VA Compensation and Pension (C&P) evaluation, 11 months after separation, the CI reported numbness in the back of his left leg that went down into the heel and constant pain graded 6/10.  He reported two flare-ups, three times a week, lasting 1-2 days and so severe he had to go home from work.  The CI denied bladder, bowel or sexual dysfunction.  The VA examination documented the date of the CI’s surgery with laminectomy and filum sectioning as December 2004 (NARSUM date December 2003), which appeared to the panel to be a date error and not a second surgery.  Physical examination showed an antalgic gait but normal posture.  There was no palpable tenderness or muscle spasm.  Thoracolumbar ROM was flexion of 0 degrees (normal 90).  The CI stated he was unable to flex due to pain.  Extension was 10 degrees (normal 30). Left lateral flexion was 0 degrees (30 normal), right lateral flexion was 15 degrees (30 normal).  Left and right rotation were 25 degrees bilaterally.  There was no additional limitation with repetition.  The CI was able to toe walk, but unable to do heel walking or heel-to-toe walking due to pain.  No ambulatory devices were used.  Sensation to pinprick was decreased in the left lower extremity and bottom of the foot.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbar spine strain).  The VA rated the back condition 40%, coded 5010-5242 (degenerative arthritis of the spine), based on the C&P examination 11 months after separation, citing flexion of the thoracolumbar spine 30 degrees or less.  

The panel was challenged as the STR did not contain ROM findings proximate to separation.  Physical therapy notes documented at least intermittent “decreased” ROM, with painful motion, but it was not clear that the limitation of ROM was sufficient for the higher 20% rating for limitation of flexion (greater than 30 degrees but not greater than 60 degrees and/or combined ROM not greater than 120 degrees).  Although the VA examination documented severe limitation of motion, the examiner documented that the CI essentially declined to move at all (flexion 0 degrees) due to pain.  The inability to forward flex due to subjective pain was also not consistent with the objective absence of spasm and tenderness which was documented at the same examination.  VA rating guidance indicates that the full extent of active ROM with pain is the basis for a ROM rating, and not the presence of pain with motion itself.  Therefore, the panel concluded that the VA examination did not provide valid ROM evidence for rating.  There was no evidence in the record from which to conclude that the severity at separation approached that portrayed by the VA measurements.  In considering other pathways to a higher rating, it was noted that although there were muscle spasms noted at examinations in the STR, at examinations proximate to separation they were not severe enough to result in an abnormal gait or spinal contour and at the MEB NARSUM and VA examinations no muscle spasm was documented, thus the next higher 20% rating was not justified on this basis.  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 low back condition.    

BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.71a, the panel unanimously or majority 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 20160930, 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-2016-01212.

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.  The Board recommended no re-characterization or modification of your separation.

I 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.  I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings