RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX  	CASE:  PD-2017-01831
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060509

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E5, Wheeled Vehicle Mechanic, medically separated for “chronic low back pain” with a disability rating of 10%.   

CI CONTENTION:  “PTSD was not evaluated/rated.”  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 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 - 20060317	VARD - 20060929	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5241	10%	Residuals, Laminectomy, L-S Spine	5237	20%	20060807	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent lumbar decompression surgery and a spinal fusion at L5-S1 in January 2005.  Thoracolumbar range of motion (ROM) testing by physical therapy (PT) on 2 June 2005, 5 months after surgery, showed flexion of 15 degrees (normal 90) and combined ROM of 95 degrees (normal 240), after repetition, with mechanical based limitation.  

The 18 October 2005 MEB NARSUM examination, 7 months prior to separation, noted complaints of continued pain with flexion, lifting and twisting motions.  Radiographic studies indicated the fusion was not solid and on 9 May 2006, the CI underwent revision surgery.  Postoperatively he developed a cerebrospinal fluid leak, which required additional surgeries on 28 June 2006 and 10 July 2006.  

At the 7 August 2006 VA Compensation and Pension (C&P) examination, 3 months after separation and revision surgery, the CI reported daily 5/10 low back pain.  Physical examination of the lumbosacral spine revealed tenderness, straightening of the lordotic curvature, mild paraspinous spasms, and pain and stiffness with heel walking.  Thoracolumbar range of motion (ROM) measurements showed flexion of 70 degrees and combined ROM of 165 degrees.  

At the 26 April 2007 VA C&P examination, 12 months after separation, the CI reported constant low back “pressure” localized at L5-S1 over the laminectomy scar.  Physical examination showed a normal, brisk gait and no obvious asymmetry, deformity or abnormal spinal curvature.  Forward flexion was 90 degrees and combined ROM was 240 degrees without pain. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5241 (spinal fusion), citing a normal gait and decreased ROM of back due to pain with bending, twisting and lifting.  The VA rated the back condition 20%, coded 5237 (lumbosacral strain), based on the C&P examination, citing straightening of lordotic curvature with mild paraspinous spasms.  

The panel noted the PT ROM measurement of 15 degrees held little probative value since it was taken prior to the revision surgery.  Therefore, panel members agreed the post-separation VA examination was closer to separation and more accurately represented the CI’s disability at the time of separation.  The panel next agreed that a 10% rating, but no higher, was justified for limitation of flexion greater than 60 degrees but not greater than 85 degrees, as reported on the VA examination.  Although there was muscle spasm, it was mild and more likely than not, was insufficient to account for a higher rating that requires spasm severe enough to result in an abnormal spinal contour.  The CI underwent spinal fusion at L5-S1 and as a result there was a loss of lordosis which is a known finding as a component of the post-laminectomy syndrome as reported in the medical literature.  The panel also noted that at a follow-up VA examination, spinal curvature had normalized.  Thus the next higher rating of 20% 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 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.  

	PD-2017-01831

AR20190015707, XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXX

	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.

	PD-2017-01831