RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01475
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040430

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Mobile Subscriber Equipment Network Switch System Operator, medically separated for “status post spinal fusion” with a disability rating of 20%.

CI CONTENTION:  Used evidence supports a higher rating.  Current conditions supports 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 (VA), 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 - 20040126	VARD - 20040720	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Status Post Spinal Fusion	5241	20%	Status Post Spinal Fusion	5241	40%	STR	
	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Low Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition insidiously began in 1998.  In December 1998 x-ray imaging revealed decreased bone density of the lower thoracic segments as well as loss in height of the vertebral bodies.  Conventional treatment did not relieve the CI’s painful symptoms.  Follow-up X-rays revealed multiple compression fractures of the lower thoracic spine.  An initial spinal fusion was performed on 30 December 2002 and a second follow-on corrective surgery was performed on 06 January 2003.  

The 31 October 2003 MEB NARSUM examination, 6 months prior to separation, noted complaints of back pain and significant functional limitations while wearing a ruck sack, running, push-ups and sit-ups.  His physical examination (PE) revealed a normal gait and no spinal muscle spasms.  The “trunk” range of motion (ROM) was flexion to 40 degrees (thoracolumbar normal 90) and extension to 10 degrees (thoracolumbar normal 30).  Painful motion was not addressed.  During a 21 November 2003 physical therapy (PT) evaluation, 5 months prior to separation, spinal ROM measurement was 50 degrees of flexion and the combined ROM was incomplete; painful motion was not addressed.  At the 22 January 2004 MEB PT evaluation, 3 months prior to separation, goniometric “lumbar” ROM from “L1-L5” vertebrae was flexion to 10 degrees and combined ROM was incomplete; painful motion was not addressed.  There was no VA examination proximate to separation for the panel to review.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the spinal fusion condition 20%, coded 5241 (spinal fusion), citing thoracolumbar spinal flexion limited to 40 degrees.  The VA rated the spinal fusion condition 40%, also coded 5241, based on the STR, citing limitation of flexion of the thoracolumbar spine at 30 degrees or less.  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 documented by the preponderance of STR evidence proximate to separation.  Although the January 2004 PT evaluation recorded flexion at 10 degrees of the “lumbar” spine (from “L1-L5”), the panel agreed that this measurement was not in accordance VASRD §4.71a General Rating Formula for Diseases and Injuries of the Spine which notes the measurement of the “thoracolumbar” spine.  The panel also considered intervertebral disc syndrome but there was no documentation of 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 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 status post spinal fusion 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 20161012, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20180001607, 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