From: To:

DEPARTJ.l.::IENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309 WASHINGTON NAVY YARD, DC 20374

IN   REPLY   REFER  TO:
1850
CORB:003
20 Feb 20

Director, Secretary of the Navy Council of Review Boards 
PD-2017-00202

Subj: Ref:

PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

(a) DoDI 6040.44
(b)	PDBR ltr dtd 19 Dec 18

1.	Pursuant to reference {a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy.

2.	On 12 February 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR of no change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.

RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE: PD-2017-00202 BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20040713

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E-5, Electronics Control Maintenance, medically separated for “epidural fibrosis at S1” with a disability rating of 10%.

CI CONTENTION:  No specific contention was made. 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 Medical Evaluation Board (MEB), but determined by the PEB 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. The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate. The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20041115	NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Epidural Fibrosis at S1	5299-5238	10%	
No VA Examination Proximate to Separation in Evidence	
Status Post Left L5-S1 Herniated Disks	
Cat II		
S1 Radiculopathy			
Postoperative Pain			
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: NA	
	
ANALYSIS SUMMARY:

Epidural Fibrosis at S1. According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent L5-S1 micro discectomy in December 2003 for herniated disc with impingement of the left S1 nerve root. At a primary care visit on 3 February 2004, the CI reported some numbness of the left lower extremity (LLE) from the thigh to mid-calf since surgery, but no back pain. There was full ROM of all extremities with normal sensation. A neurosurgery follow- up visit on 26 February 2004 noted LLE pain, improved since surgery, but still persistent. Recent

MRI showed no recurrent or residual disc material, but there was quite a bit of scarring around the nerve (epidural fibrosis at S1). At the 9 March 2004 MEB NARSUM examination, 4 months prior to separation, the CI reported daily back pain, but no physical examination was documented. During the 21 April 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported he was “unable to climb or stand very long” due to back pain. The spine, neurologic and lower extremity evaluations were checked normal. The CI reported doing well at a primary care visit on 29 April 2004. There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the sparse evidence above. The PEB rated the back condition 10%, analogously coded 5299-5238 (spinal stenosis). The PEB listed status post left L5-S1 herniated disks, S1 radiculopathy and postoperative pain as related Category II diagnoses contributing to the disability in this case. The panel concluded the Category II diagnoses were not separate conditions which could be reasonably justified as separately unfitting; nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding). There was insufficient rating evidence available in the record for the panel to recommend a rating under the VASRD general spine rating rules. The examinations in record after the CI’s surgery did not provide ROM evidence or comment on tenderness, muscle spasm or guarding and the MEB examination showed normal spine, neurologic and lower extremity evaluations.

The panel agreed that a 10% rating for mild neuritis of the sciatic nerve (8620) was supported at separation based on the CI report of numbness and continued pain of the LLE due to scarring of the S1 nerve. There was no evidence of LLE weakness or objective sensory loss in the record to recommend a higher rating for moderate neuritis of the sciatic nerve. There was no evidence of intervertebral disc syndrome, which resulted in incapacitating episodes requiring physician- prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition. There was therefore no higher than a 10% rating supported under any applicable VASRD code. Although the panel’s 10% rating recommendation relied upon a different code than the PEB, there is no rating benefit to the CI and therefore no change to the PEB code is recommended. After due deliberation, considering all 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 back condition.

BOARD FINDINGS: In the matter of the back condition and IAW VASRD §4.71a, the panel 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 20161006, w/atchs 
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

2	PD-2017-00202