RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01509
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20041206

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Fire Protection Journeyman, medically separated for “burst fracture L2” with a disability rating of 10%.

CI CONTENTION:  The CI makes no specific contentions.  The 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 - 20040930	VARD - 20050110	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Burst Fracture L2	5235	10%	Postoperative Residuals Lumbar Burst Fracture L2	5241	10%	20040505	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Burst Fracture L2.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI sustained an L2 burst fracture on 6 June 2003 after falling 12-20 feet on to his feet.  An emergency MRI showed the burst fracture.  On 11 June 2003 the CI underwent a retroperitoneal L2 vertebrectomy (removal of part of the vertebral body) with hardware placement.  Following surgery, he did well with rehabilitation; however, profile limitations (from the surgery) precluded his return to fire protection duties.  Post-surgical X-ray showed a good repair.

A 2 September 2004 Neurosurgical NARSUM addendum, 3 months prior to separation, revealed the CI reported significant back pain limiting walking and lifting.  Neurological signs and symptoms showing pathology were absent.  The strength was normal.  The 20 September 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of intermittent low back pain and occasional numbness over the left anterior thigh.  Physical examination showed a well-healed horizontal incision over left antero-lateral abdomen.  Tenderness to palpation over the lumbar area was absent.  There was slightly decreased sensation of left anterior thigh compared to right.  Strength, reflexes, and gait were normal.  The range of motion (ROM) was not recorded.

At the 5 May 2004 VA Compensation and Pension (C&P) evaluation, 5 months after separation, the CI reported diminished lumbar spine ROM, pain after extended walking, and occasional tenderness over the anterior thigh.  Physical examination showed a normal gait.  There was a well-healed left lower thoracotomy scar with no tenderness to palpation over lumbar spine.  Lordosis (normal spinal curvature) was present with no paraspinal muscle spasm.  Straight leg raise test for radiculopathy was negative, gait was normal.  Repetitive-goniometric ROM was flexion to 80 degrees (normal 90) and the combined ROM was 220 degrees (normal 240); painful motion was present.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5235 (vertebral fracture or dislocation), citing DOD and VASRD guidelines.  The VA also rated the low back condition 10%, coded 5241, (spinal fusion), based on the C&P examination 5 months after separation, citing limited ROM.  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) or a combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the VA examination.  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.  Incapacitation was not recorded after the initial injury.  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 burst fracture L2 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.  The panel recommends t 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 20161013, with attachments
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

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-01509.

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