RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE: pd-2017-00973
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20080929

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Vehicle Operations Craftsman, medically separated for “low back pain secondary to degenerative disc disease” with a disability rating of 10%.

CI CONTENTION:  “Please consider all conditions.”  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 - 20080804	VARD - 20081224	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5243	10%	Lumbosacral Spine DDD	5242	40%	20081203	
Cervical Disc Disease	Cat II	Cervical Spine DDD	5242	20%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:

Low Back Pain (LBP).  According to the service treatment record and MEB narrative summary (NARSUM), the CI was first evaluated for LBP in August 1996 when he felt his back “go out” while bending over.  His condition waxed and waned over the years.  On 14 July 2004, an MRI of the lumbar spine showed mild degenerative disc disease (DDD), but was otherwise normal.  The record then falls silent until a family practice clinic note on 30 January 2006 where he was noted to have normal range of motion (ROM) of the back.  Two months later in primary care, the thoracolumbar ROM was limited (not quantified) and painful, but lumbosacral ROM was full and painless.  In the emergency room (ER) on 29 June 2006, the ROM was full (without limitations) but painful.  One week later in family practice, the CI was noted to have full ROM of the thoracic and lumbar spine with tenderness and spasm of the lumbar muscles.  An MRI dated 7 July 2006 showed a bulging disc at L1-2 with herniation at L4-5.  DDD was noted at L3-4 and L5-S1.  Surgery was not thought to be a good option.  In primary care on 3 May 2007, the CI was noted to have full but painful motion of the thoracolumbar spine.  In internal medicine on 2 August 2007, the CI was noted to have abnormal motion of the thoracolumbar spine without further explanation.  A 6 August 2007 MRI showed multi-level DDD with a disc bulge at L4-5 and a disc tear with a bulge at L5-S1.  Disc herniation was not present.  A discogram, a provocative test for disc disease, on 4 October 2007 showed pain at L3-4; there was no pain at the other levels after injection of contrast.  At a follow-up in neurosurgery on 6 December 2007, surgery was not recommended.    

The 18 March 2008 MEB NARSUM examination, 7 months prior to separation, noted complaints of daily back pain aggravated by activity with occasional pain radiating down both legs.  He reported that over the prior 6 months, he had left work early twice and called in sick twice due to the back pain.  The physical examination showed a normal gait and spinal contour.  Tenderness was present.  Provocative testing for radiculopathy was normal.  The neurological examination was normal.  Lumbosacral ROM testing showed flexion of 90 degrees (normal 90).  Side bending and extension were normal, but rotation not recorded.  However, the thoracolumbar spine (which includes most of the spine rotation) was recorded as showing no abnormalities.  Muscle spasm was not recorded.  

The commander’s statement dated 14 April 2008 noted the CI was limited to desk duties, but also that he had not missed any duty the past 90 days nor had his duty schedule been modified.  At the 14 August 2008 family practice visit, 2 months prior to separation, the CI complained of LBP.  The examiner documented no interval change or injury since PEB.  Physical examination showed a normal spinal contour with tenderness and muscle spasms.  Thoracolumbar ROM exhibited pain with flexion and extension, but the ROM was not recorded.  

During the 03 December 2008 VA Compensation and Pension (C&P) general examination, 2 months after separation, the CI reported constant lumbar back pain aggravated by heaving lifting, prolonged sitting, and bending.  He denied loss of bowel or bladder control.  He was working as a car salesperson and had left work early once for back discomfort.  He was able to perform the activities of daily living.  He reported a flare in 2006 in which he presented to the ER and that there had been no such recurrences.  A recent increase in his pain or limitations was not recorded.  On physical examination, the CI was in no acute distress, but appeared to have a stiff back and turned his whole body to face the examiner during the interview.  He had a normal gait and posture and was able to heel-toe and tandem walk without difficulty.  The spinal contour was normal.  There was some spinal tenderness; spasm was not recorded.  The neurological examination was intact.  Provocative testing for nerve root irritation was positive bilaterally when supine.  The examiner did not record any difficulty with either lying down or sitting back up.  No difficulty was recorded when rising from a sitting position.  Lumbar spine (not thoracolumbar) ROM showed flexion to 30 degrees and combined ROM was 145 degrees (normal 240) without painful motion.  The ROM was reduced after 10 (not 3) repetitions resulting in flexion to 20 degrees and combined ROM 115 with painful motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5243 (intervertebral disc syndrome), citing no spinal tenderness.  The VA rated the low back condition 40%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing limitation of flexion.  The panel considered the evidence.  The majority of examinations prior to separation recorded tenderness and pain with motion, but full ROM for the thoracolumbar spine.  The VA C&P examination was an outlier from the previous examinations.  It recorded flexion of 30 degrees (before repetition) of the lumbar spine (rather than measuring the thoracolumbar spine).  The panel observed that the lumbar spine flexion is less than for the full thoracolumbar spine and that the latter is used for rating purposes in the VASRD.  The panel also observed that the CI was in no distress, had a normal gait and posture, and that difficulty with changing positions was not documented.  Spasm, which can reduce the ROM, was not recorded nor was a recent aggravation of the condition.  The probative value of the VA examination is reduced and it was not used for rating purposes.  The panel agreed that a 10% rating, but no higher, was justified for tenderness and painful motion.  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.  There was no documentation of intervertebral disc syndrome with 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 there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.

Contended PEB Condition:  Cervical Disc Disease.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled at separation, implicated in the commander’s statement, nor judged to fail retention standards.  The MEB NARSUM listed it in the past medical history (as opposed to a current problem) and the MEB did not address it.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended cervical disc disease, the panel recommends no change from the PEB determination as not unfitting.  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 20170209 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 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-2017-00973.

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