RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01600
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080821

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Bradley Linebacker Crewmember, medically separated for “lumbar fusion L1-L2” with a disability rating of 20%.  

CI CONTENTION:  The CI requested review of his low back pain and 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 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 - 20080403	VARD - 20090120	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar Fusion L1-L2	5241	20%	Degenerative Disc Disease of Lumbar Spine	5241-5010	10%	20090105	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Lumbar Fusion L1-L2.  According to the service treatment record and the MEB narrative summary (NARSUM), the CI underwent back surgery for transforaminal lumbar interbody fusion at L1-L2 in May 2006 for degenerative disc disease.  He had continued back pain with radiation and was not considered a candidate for further surgery.  The 17 December 2007 physical therapy (PT) evaluation showed a normal gait.  There was back tenderness and muscle spasm.  Range of motion (ROM) measurement revealed flexion of 70 degrees (normal 90) and combined 180 degrees (normal 240).  An inclinometer was used except for rotations.  Motion was mechanically limited by lumbar fusion and due to pain.  

The 10 January 2008 MEB NARSUM examination, 7 months prior to separation, noted complaints of low back pain.  Physical examination showed a well-healed surgical incision with back tenderness and spasm.  The 21 March 2008 PT MEB ROM measurements documented flexion of 45 degrees and combined 145 degrees.  There was limitation due to pain, pain on repeated use, tenderness, an abnormal contour, and an abnormal gait due to muscle spasm and/or guarding.  

At the 5 January 2009 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported back pain.  The examiner found a normal gait with no back tenderness.  There was painful ROM of flexion 80 degrees, and combined 200 degrees.  Subsequent VA treatment notes on 12 May 2009 showed isolated flexion of 30 degrees (no repetition or other measurements) with a normal gait; and a treatment note on 7 August 2009 showed pain limited flexion to 40 degrees and combined 170 degrees after repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 20%, coded 5241 (spinal fusion), citing forward flexion of 48, 45, and 46 degrees (with goniometer).  The VA rated the low back condition 10%, dual coded 5241-5010 (spinal fusion - arthritis, due to trauma), based on the C&P examination, citing pain on motion and reduced ROM.  A subsequent VARD increased the back rating to 20%, effective 15 June 2009, citing the above VA treatment notes.  

The panel agreed that 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-PT examinations.  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 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.  

BOARD FINDINGS:  In the matter of the lumbar fusion L1-L2 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 20170301, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record  

AR20180008634, XXXXXXXXXXXXXXXXXX

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.

Sincerely,					      
Enclosure