RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02092
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040820

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty W-1, C2 Systems Technician, medically separated for “degenerative disc disease of the cervical spine” and “degenerative disc disease of the thoracolumbar spine,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  “Rating should be higher.” The CI requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB). 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 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 - 20040709	VARD - 20050322	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Multilevel Degenerative Disc Disease (DDD) of the Cervical Spine	5299-5243	10%	Multilevel Cervical Spine DDD and Spondylosis	5243	20%	20050114	
Multilevel Thoracolumbar Spine DDD	5299-5243	10%	Mild Thoracic Spondylosis Retrolisthesis of L5 on S1 with Lumbar Spondylosis	5243	10%	20050114	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Multilevel Cervical Spine DDD.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s neck condition began in 1999 after performing push-ups.  He reinjured the neck condition in August 2001 during an airborne mission and then exacerbated this neck condition in September 2003.  He received physical therapy, traction, and medication during this extended period.  Cervical spine X-rays and an MRI performed in April 2004 showed cervical spine DDD.  The CI was able to perform activities of daily living, but impact or weight-bearing activities or prolonged standing and sitting significant pain.

During a 20 April 2004 MEB NARSUM consultation, 5 months prior to separation, the CI reported worsening neck pain.  Physical examination revealed a non-antalgic gait.  Bilateral upper extremity motor strength was 5/5 in all muscle groups and sensation was intact throughout.  Bilateral reflexes were trace and symmetric.  Cervical spine range of motion (ROM) was “full”; painful motion was not addressed.  

The 15 June 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of constant neck and bilateral shoulder pain with pain going down the arms and occasional numbness or tingling in the fingers.  Physical examination revealed a normal gait and cervical spine tenderness.  Goniometric-measured cervical spine flexion was 45 degrees (normal) and combined ROM was 300 degrees (normal 340); painful motion was not addressed.

At the 14 January 2005 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported constant neck pain that shot up to his head.  Physical examination showed a normal gait and posture, and cervical spine tenderness.  Cervical spine flexion was 45 degrees and combined ROM was 260 degrees; painful motion not addressed.  There was no additional limitation of motion with repetition.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, analogously coded 5299-5243 (intervertebral disc syndrome (IVDS)), citing cervical spinal tenderness.  The VA rated the neck condition 20%, also coded 5243, based on the C&P examination, citing VASRD criteria for a 20% rating.

Although there was insufficient limitation of motion to support a 10% rating as recorded on the STR and VA ROM examination evidence, the panel agreed a 10% rating was justified for the presence of cervical tenderness.  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 that basis.  There was no IVDS documentation with incapacitating episodes that provides for a higher rating under that formula.  The panel also noted there was no objective evidence of a radiculopathy with functional impairments (such as upper extremity weakness) nor performance-based evidence from the record that this condition significantly interfered with satisfactory duty performance at separation.  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 neck condition.  

Multilevel Thoracolumbar Spine DDD.  According to the STR and MEB NARSUM, the CI’s back condition began in 1995 while participating in an air assault mission.  As noted above, he reinjured the back condition in August 2001 during an airborne mission and then exacerbated this back condition in September 2003.  Treatment for the thoroaolumbar spine was identical to that for the cervical spine condition to include PT, traction, and medication during an extended period.  Thoracolumbar spine X-rays and an MRI performed in April 2004 showed thoracolumbar spine DDD.  As with the cervical spine condition, the CI was able to perform activities of daily living, but impact or weight-bearing activities or prolonged standing and sitting caused significant pain.

During the MEB NARSUM the CI reported worsening back pain.  Physical examination revealed a non-antalgic gait.  Bilateral lower extremity motor strength was 5/5 in all muscle groups and sensation was intact throughout.  Bilateral reflexes were 1+ (a slight but definitely present response) and symmetric.  Thoracolumbar spine ROM was “full”; painful motion was not addressed.  The 15 June 2004 MEB NARSUM examination noted complaints of constant pain in the lower and middle back.  Physical examination revealed a normal gait and thoracolumbar spine tenderness.  Goniometric-measured thoracolumbar spine flexion was 90 degrees (normal) and combined ROM was 170 degrees (normal 240); painful motion was not addressed.

At the C&P examination the CI reported intermittent pain between his shoulder blades that occurred suddenly with no particular motion or activity; flare-ups could last 2 hours.  The CI reported pain on the left and right side of the spine.  Physical examination showed a normal gait and posture, and thoracolumbar spinal tenderness.  Thoracolumbar spine flexion was 80 degrees and combined ROM was 215 degrees; painful motion was not addressed.  There was no additional limitation of motion with repetition.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5243, citing thoracolumbar spine tenderness.  The VA rated the back condition 10%, also coded 5243, based on the C&P examination, citing limitation of flexion.

Although there was insufficient limitation of motion recorded in the STR and MEB NARSUM ROM examinations to support a 10% rating, the panel agreed that a 10% rating was justified for the presence of thoracolumbar spine tenderness.  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 that basis.  There was no IVDS documentation with incapacitating episodes that provides for a higher rating under that formula.  The panel also noted there was no objective evidence of a radiculopathy with functional impairments (such as lower extremity weakness) nor performance-based evidence from the record that this condition significantly interfered with satisfactory duty performance at separation.  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 neck condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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.

AR20180014736, 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.