RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01387
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041202

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Track Vehicle Repairer, medically separated for “low back pain” and “neck pain,” rated 10% each, with a combined disability rating of 20%. 

CI CONTENTION:  “unemployable for insurance reasons, chronic pain renders immobile at times.”  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 - 20040913	VARD - 20041216	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5241	10%	Residuals of Low Back Injury…Status Post Fusion	5010-5241	20%	20040915	
			Residual of Low Back Pain…Left Lower Extremity	8520	10%	20090915	
Neck Pain	5243	10%	Residuals of Neck Injury…Postoperative	5010-5237	10%	20040915	
			Residuals of Neck Injury, Right Upper extremity Neuropathy	8515	10%	20040915	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began spontaneously in April 2000 while performing physical training.  In November 2000, the CI underwent a disk excision and fusion of L5-S1.  On 2 April 2003, CI underwent a posterior spinal fusion of L5-S1 with segmental instrumentation, decompression of the left L5-S1 foramen, and bone grafting.  Postoperatively the CI had some residual back pain resulting in a permanent profile with mild limitations including no running or running at own pace and distance.  On 5 March 2003, computed tomography (CT) demonstrated postoperative change at L-5 and S-1 (consistent with a fusion procedure) as well as subtle bony bridging between L-5 and S-1.  In March 2004, the CI underwent a third surgery for removal of screws and rods.  X-rays of the lumbosacral spine on 15 June 2004 showed status post fusion of L5-S1 with the hardware intact and without loosening and with arthritic changes of the facet joints and narrowing of the neuroforamen with spinal stenosis to be excluded.  

The 10 June 2004 MEB NARSUM examination, 6 months prior to separation, noted complaints of low back pain with radiculopathy to the left lower extremity.  Physical examination showed the range of motion (ROM) was decreased with the CI able to bend forward and bring his fingertips to the level of the knees.  Lateral bending was severely uncomfortable.  Straight leg raise (to determine nerve root irritation) was accomplished without a positive sciatic stretch sign (pain).  There was decreased sensation of the left leg, extending to the dorsum of the lateral aspect of the foot and fourth and fifth toes was noted.  Slight clonus (involuntary, rhythmic, muscular contractions and relaxation) was present on muscle strength testing, which was 4/5 on the left and 5/5 on the right. Clonus was noted on dorsiflexion of the left foot against resistance.  

At the 15 September 2004 VA Compensation and Pension (C&P) evaluation, 3 months before separation, the CI reported intermittent back pain, which occasionally awakened the CI at night and required pain medication.  Physical examination showed a normal gait, musculoskeletal strength 5/5, deep tendon reflexes 2+ bilaterally, and no focal or lateralizing signs.  Sensory discrimination to sharp/dull was present.  ROM after five repetitions was flexion was 45 degrees (normal 90), and combined ROM of 135 degrees (normal 240).  The straight leg raise test was negative.  Lordosis (excessive inward curvature of the spine) was present and no paraspinous muscle spasm was noted, but there was tenderness over the lower lumbosacral spine.  Diminished sensation was present along the left lateral leg; deep tendon reflexes were 2+ bilaterally; and strength was 5/5.  No ankle clonus was noted with normal reflexes.  There was strong dorsiflexion of the great toes bilaterally.  The CI was able to walk on his toes, heels and tandem walk.  His gait was normal and there was no spinal kyphosis or scoliosis.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back pain condition 10%, coded 5241 (spinal fusion), citing pain in all ranges of motion with forward flexion noted at 65 degrees (passive ROM).  Straight leg raising was accomplished without a positive sciatic stretch sign.  The VA rated the back condition 20%, coded 5010-5241 (arthritis, due to trauma–spinal fusion), based on the C&P examination 3 months before separation, citing decreased ROM with pain on motion.  The VA additionally rated the left lower extremity radiculopathy 10%, coded 8520, (sciatic nerve, paralysis of), based on the C&P examination 3 months before separation, citing diminished sensation in the general stripe band along the left lateral leg.  The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) as reported on the C&P examination, which was more proximate to separation than the NARSUM.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes, which would provide for a higher rating under that formula (for IVDS).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the back condition, coded 5241.  

Neck Pain.  The CI underwent a C5-6 discectomy In April 1999.  Postoperatively, the neurological function to his right upper extremity was delayed.  After 1½ years of therapy, there remained numbness to the index finger, long finger and thumb on the right, as well as the ulnar aspect of the forearm.  After the back surgery In April 2003, the CI’s radicular symptoms increased with pain at the right upper extremity.  An undated MRI showed spinal stenosis at C5-6 on the right.  On 15 June 2004, X-rays studies revealed mild degenerative disc disease C6-C7 and to a lesser degree C5-C6 with narrowing of the neural foramina of C6-C7 on the right side and of C5-C6 on the left side.   

The 10 June 2004 MEB NARSUM examination noted complaints low back pain and radiculopathy of the right upper extremity.  Physical examination showed cervical range of motion rotation to the right and left 40 degrees (normal 80), right lateral tilt 20 degrees (normal 45), and left lateral tilt “extremely limited” (normal 45).  Upper extremity reflexes were normal, however, decreased sensation of the right thumb, index and the long finger was noted.  Grip strength was decreased.  Flexion was 40 degrees (normal 45) after three repetitions on 3 September 2004.  

At the 15 September 2004 C&P examination the CI reported intermittent pain present in the right upper extremity radiating through digits one through three, which frequently awakened him at night.  “Some” strength loss was noted in the dominant right hand.  Physical examination showed no pain on palpation.  ROM measurements (after five repetitions) were flexion 35 degrees and combined 175 degrees (normal 340).

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5243 (intervertebral disc syndrome) citing decreased sensation along the thumb and index finger on the right (C5/C6), decreased grip strength, and forward flexion at 40 degrees.  The VA also rated the neck condition 10%, coded 5010-5237 (arthritis-cervical strain) based on the C&P examination 3 months before separation, citing painful decreased ROM.  The VA additionally rated the right upper extremity neuropathy as part of the residual neck injury, coded 8515 (paralysis medial nerve), citing decreased grip strength in the right upper extremity with diminished sensation of the thumb, index, and long finger.  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 40 degrees) as reported on the VA examination proximate to separation.  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 (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).  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 back condition, the panel unanimously recommends a disability rating of 20%, coded 5241 IAW VASRD §4.71a.  In the matter of the neck condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Low Back Pain Post Discectomy and L4/S1 Fusion	5241	20%	
Neck Pain Post C5/C6 Discectomy	5243	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161003, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170018959, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to recharacterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The recharacterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure