RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01388
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041014

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Information Systems Operator Analyst, medically separated for “low back pain status post L5-S1 fusion” with a disability rating of 10%.  

CI CONTENTION:  The condition was much worse than diagnosed and warranted a higher rating.  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 it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:  

SERVICE PEB – 20040707 	VARD – 20041019 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain 	5241	10%	Degenerative Disc Disease Lumbosacral	5241	10%	20040825	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Low Back Pain (LBP).  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent an L5-S1 transforaminal lumbar interbody fusion in January 2004.  He had good recovery, although he experienced increased low back pain with increased activity at work.  The 27 April 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of slight and constant back pain.  Thoracolumbar range of motion (ROM) measurements performed by physical therapy showed flexion of 70 degrees (normal 90) and combined ROM of 205 degrees (normal 240), without painful limitation.  

At the 25 August 2004 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported sharp 8/10 LBP with radiation into the lower extremities.  He had flare-ups with strenuous physical activity or abnormal turns.  Physical examination showed no muscle spasm.  Gait was adynamic (loss of strength or normal function), and no assistive devices were required.  Lumbosacral flexion was 0-80 degrees and combined ROM was 200 degrees.  There was stiffness and discomfort on repetitive use.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5241 (spinal fusion), citing combined ROM of 260 degrees and intermittent narcotic medication.  The VA also rated the low back condition 10%, coded 5241, based on the C&P examination 2 months before separation, citing flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined ROM of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees.  

The panel agreed a 10% rating, but no higher, was justified for limitation of flexion greater than 60 degrees but not greater than 85 degrees as reported on all examinations 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 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 low back condition.  

BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.71a, 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 20161005, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180001574, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
Enclosure