RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00671
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20060807

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Munitions Systems Craftsman and Military Equal Opportunity Apprentice, medically separated for “back pain” with a disability rating of 20%.  

CI CONTENTION:  His conditions continue to worsen.  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 - 20060601	VARD - 20070208	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Back Pain 	5243	20%	Status Post Lumbar Laminectomy and Diskectomy	5243	40%	20061205	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent lumbar discectomy at L5-S1 in 2001.  At a 30 June 2004 primary care clinic (PCC) visit, the CI reported progressively worsening low back pain (LBP).  Lumbar MRI on 26 February 2005 showed degenerative disc disease (DDD) of the thoracic spine and a residual disc bulge to the right at L5-S1 along with degenerative joint changes causing neuroforaminal narrowing bilaterally.  During the PCC visit on 2 August 2005, the CI was seen for LBP that radiated down both legs with spasms, but was noted to have full range of motion (ROM).  

In September 2005, the CI was evaluated by neurosurgery and reported right side pain with alternating symptoms, alternating numbness and sexual dysfunction.  Physical examination noted numbness from the right umbilical area to the entire lower limb.  Thoracic MRI on 25 October 2005, showed diffuse DDD with narrowing of the neuroforamen and central canal stenosis in the mid cervical spine, without evidence of spinal cord injury.  Lumbar spine computed tomography (CT) scan on 25 October 2005 confirmed the most recent MRI findings and showed evidence of bulging of the L5-S1 residual disc components associated with arthrosis causing stenosis of the right neural foramen.  Electrodiagnostic studies were normal and no surgery was recommended.  

At the PCC visit on 6 April 2006, 4 month prior to separation, the CI complained of LBP that radiated down the back of the right lower extremity (RLE) to his knee.  He denied weakness or bowel or bladder problems.  Pain occurred with running, biking, pushups, sit-ups or lifting over 20 pounds.  Physical examination showed tenderness.  ROM testing showed forward flexion of 80 degrees (normal 90) and right lateral flexion of 10 degrees (normal 30).  

The 10 April 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of constant 2/10 back pain, persistent RLE numbness and erectile dysfunction (ED).  Pain was aggravated by lifting over 20 pounds, running, prolonged sitting or doing sit-ups, but was able to work out on the elliptical trainer 6-7 times per week.  Physical examination showed a normal gait and no tenderness.  ROM testing showed flexion of 40 degrees and combined ROM of 190 degrees (normal 240).  Strength and reflexes were normal, but straight leg raise testing, to elicit radicular symptoms, was positive on the right.  

At the 14 November 2006 VA Compensation & Pension joints examination, 3 months after separation, the CI reported LBP with sciatic pain bilaterally, but worse in the right side.  He also had numbness in the RLE. He found it hard to sit or stand for any length of time, but was able to drive a car, and could sit at home on a couch or a recliner.  He took Flexeril (skeletal muscle relaxer) twice a day for muscle spasm and at times he felt the right leg was going to fold up underneath him.  The CI reported no flare-ups during the year before the exam, but reported a steady downhill course.  Physical examination showed forward flexion of 10 degrees and combined ROM or 60 degrees.  The examiner noted the CI was not able to complete more than two or three repetitions before stating his back was too tender to keep going on forward flexion.  Strength was intact and sensation was decreased on the bottom and top of the right foot.  Reflexes were absent at the knees and ankles.  Thoracic and lumbar spine X-rays showed degenerative changes in the lower thoracic spine and lumbar spine.    

At a 1 December 2006 VA PCC visit to establish care, 4 months after separation, the CI reported his LBP had worsened in the last 3 months with weakness and numbness in the RLE.  He reported ED since the surgery.  The examiner noted the CI had poorly controlled back pain with “weakness and numbness in the RLE since 9/06.”  Physical examination noted a “halted gait.”  Strength was “decreased” and sensation was “decreased” in the right lower and right upper extremities, but lower extremity reflexes were normal.    

At a 10 January 2007 orthopedic evaluation (performed by an orthopedic resident), the CI reported LBP that radiated down both legs, right greater than left.  Physical examination showed diffuse decreased sensation of the RLE and diffuse decreased RLE strength graded 4/5 compared with 5/5 on the left, with normal reflexes.  

During the orthopedic clinic visit on 28 February 2007, 6 months after separation, the CI reported continued LBP and RLE pain.  The examiner noted the CI was on several medications for depression and methadone for pain that was not helping.  Physical examination performed by the attending orthopedic surgeon showed a normal gait, with limited forward flexion, lateral bending, and rotation of the lumbar spine.  Reflexes were absent at the knees and ankles bilaterally.  There was normal lower extremity strength and sensation without foot drop.  The orthopedic surgeon indicated that recent repeat lumbar spine MRIs showed post-surgical changes at L5-S1 without central stenosis.  He indicated that the films showed normal anatomy to his eye.  The impression was that the CI had post-discectomy syndrome.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 20%, coded 5243 (intervertebral disc syndrome), citing limitation of motion.  The VA rated the back condition 40%, coded 5243, based on the C&P examination, citing limitation of forward flexion.  Approximately 3 months after separation, the CI reported worsening LBP and pain radiating to the RLE, at times noted on examination to be associated with muscle spasms.  The back ROM at the VA examination 4 months after separation was significantly worse than the MEB NARSUM examination.  However, there was no evidence in the STR that the low back ROM was ever as severely limited during active duty as noted after separation.  The CI had written a letter to the PEB and indicated he desired to remain in the military working in the same capacity as he had been for the previous 4 years.  There was evidence in this case of post-separation worsening but panel members agreed that at separation a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) as reported on the MEB NARSUM examination.  There was no evidence of incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for intervertebral disc syndrome.  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 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 20170217, w/atchs
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-2017-00671.

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