From:
To:

Director, Secretary of the Navy Council of Review Boards
PD-2017-02055 

!N  l'ErLY  PEf'EII i·J:

27 Feb 20

Subj:	PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr of 18 Feb 19

1.	Pursuant to reference (a}, the PDBR reviewed your case and forwarded its recommendation to the Department of the Navy for appropriate action.

2.	On 21 February 2020, the Assistant General Counsel of the Navy (Manpower & Reserve Affairs) took action in your case by  accepting the recommendation of the PDBR.	Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Department of the Navy Physical Evaluation Board (PEB) from 0% to 20% without re-characterization of your discharge.

3.	For your information, since all disability ratings from 0% to 20% qualify for disability severance pay, the above stated increase will not result in your entitlement to additional compensation.

4.	The Assistant Secretary's determination, which represents final action in your case by the Department of the Navy, has been forwarded to the Navy Personnel Command for appropriate changes to your personnel records and notification to you upon completion.

RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE: PD-2017-02055 BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20070726

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty O2, Nurse Corps Officer, medically separated for “right C-8 radiculopathic pain,” “cervicalgia,” “chronic low back pain,” and “lesser occipital neuralgia on the right side,” rated overall effect, with a disability rating of 0%.

CI CONTENTION:  “Review 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 - 20070625	VARD - 20070904	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right C-8 Radiculopathic Pain	

Overall Effect	

0%	Degenerative Disc Disease Cervical Spine	5242	10%	20070723	
Cervicalgia							

Chronic Low Back Pain			Thoracic Sprain with Spondylosis and Lumbar disc Protrusion at L4-5 and L5-S1	5237	20%	20070723	
			Sciatica Associated  with Thoracic Sprain with Spondylosis and Lumbar Disc Protrusion at L4-5 and L5-S1	
5237-8720	
10%	20070723	
Lesser Occipital Neuralgia on the Right Side			Migraine Headaches	8100	10%	20070723	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 60%	

ANALYSIS SUMMARY: The PEB combined the right C8 radiculopathic pain, cervicalgia (neck pain), chronic low back pain (LBP) and right-sided lesser occipital neuralgia conditions    under a single

disability rating for “overall effect” as permitted by DoDI 1332.38 (E3.P3.4.4). The combination of multiple conditions as a single disability reflects the PEB’s determination that each condition was not separately unfit, but the functional impairment resulting from the conditions when considered together was unfitting. The panel’s initial charge in this case was therefore directed at determining if the PEB’s single overall effect rating was justified in lieu of separate unfit determinations and ratings. If the panel judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was unfitting in and of itself as shown by a preponderance of evidence. The above referenced conditions are presented separately; with separate fitness determinations and rating recommendations if indicated.

Right C-8 Radiculopathic Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s right C-8 (junction of the spine between the neck and upper back) radiculopathic pain insidiously began in mid-2006. Specifically, the CI endorsed having pain which began in the neck and radiated down the outer aspect of her right arm to the fourth and fifth fingers. A neurology clinic encounter on 12 April 2007, 3 months prior to separation noted that “…the phenomenon is transient and self-limited.” X-rays revealed degenerative disc disease (DDD) of the cervical spine. The physical examination (PE), revealed neck pain and C-8 distribution pain on the right side. There was full range of motion (ROM) of all extremities. Peripheral muscular motor activity was normal.

At the 23 July 2007 VA Compensation and Pension (C&P) examination, 3 days prior to separation, the CI reported constant neck pain that radiates “…down the arms, neck, and hands with intermittent numbness and tingling.” Aggravating factors included activities such as standing, bending or turning of her head and neck. The VA PE revealed painful and decreased cervical range of motion (ROM) noting forward flexion to 35 degrees (normal 45) and a combined ROM of 195 degrees (normal 340). There was no cervical tenderness or spasm. Peripheral motor activity, sensation and strength were normal. The CI’s diagnosis was listed as cervical DDD, per MRI, with no clinical evidence of cervical radiculopathy. The provider documented the following with regards to the CI’s condition: “This neck examination reveals limited ROM, but there are no focal neurological deficits on examination. The [CI], however, does describe radicular symptoms. Her MRI scan revealed early degenerative disc changes of the cervical spine without any evidence of nerve impingement or canal stenosis. As to the neck condition, [the CI] is limited in performing frequent bending and turning of the head and neck and performing overhead work.”

Panel members agreed that although there was decreased ROM of the cervical spine the evidence of normal sensation, motor activity, and strength of the upper extremity, as well as MRI findings of no impingement or stenosis, lent great support in concluding that there was no preponderance of evidence to support a change in the PEB adjudication that the radiculopathic pain was not separately unfitting. The panel concluded, therefore, that this condition could not be recommended for additional disability rating.

Cervicalgia. According to the STR and MEB NARSUM, the CI’s cervicalgia began in mid-2006 without injury or trauma. History pertaining to this condition is captured in the condition listed above. An MRI of the cervical spine performed on 5 June 2006 was noteworthy for small posterior disk osteophyte (bony projections) complexes from C3-C4 through C5-C6, which did not cause any significant mass effect. Nerve exiting areas were patent throughout the cervical spine.

Three months prior to separation a neurology encounter noted “no neck symptoms” under the CI’s ‘Review of Symptoms.’ The 19 April 2007 MEB examination (recorded on DD Form 2808), 3 months prior to separation, noted “normal” under neck examination. X-rays of the cervical spine performed 3 days prior to separation were completely normal.

As previously discussed, panel members agreed that although there was decreased ROM of the cervical spine near the time of separation, a preponderance of evidence did not support a conclusion that the neck condition in and of itself was separately unfitting. Therefore, this cervicalgia condition could not be recommended for additional disability rating.

Chronic LBP. According to the STR, the first documentation of LBP was a listed diagnosis on a 3 August 2006 neurology encounter. An MRI of the lumbar spine on 25 August 2006 revealed a central and left-sided protruded L4-5 disc with mild to moderate stenosis of the spinal canal. On 8 September 2006, the CI complained of central LBP and intermittent bilateral lower extremity pain into both feet. The PE revealed full but painful motion of the lower spine. A physical therapy encounter dated 29 March 2007, 4 months prior to separation, noted prolonged standing, bending, walking and lifting objects as aggravating factors of the LBP. The PE revealed full, but painful ROM of the lower spine.  Gait and stance were normal.

At the most probative VA examination, 3 days prior to separation, The CI endorsed constant LBP that intermittently radiated down both lower extremities and was associated with intermittent numbness and tingling. Symptoms may be “…somewhat relieved by taking [narcotic] medication.” The VA PE revealed thoracolumbar spinal tenderness and decreased spinal ROM which was painful noting 60 degrees of forward flexion (normal 90) and a combined ROM of 185 (normal 240). There was no evidence of spasms and the spinal curvature was normal.

Panel members deliberated and concluded that the totality of evidence from the medical records provided a preponderance of evidence to support the LBP condition as separately unfitting noting the CI’s subjective complaints, abnormal X-rays and PE findings, limited spinal motion, and aggravating factors which were imperative in performing successfully in her nursing occupation. Such findings further support a maximal compensable rating of 20% due to the limitation of spinal motion.   Therefore, after due deliberation, considering all the evidence and mindful of   VASRD
§4.3, the panel recommends t the low back condition be found separately unfitting and rated 20%, coded as 5099-5003.

Right-sided Lesser Occipital Neuralgia. According to the STR and MEB NARSUM, the CI’s occipital neuralgia came to the attention of the neurology department in May 2006. An MRI of the brain was essentially normal. A neurology encounter on 3 August 2006 noted that the CI was taking a medication for the lesser occipital neuralgia with “some relief.” The limited duty status as of 19 March 2007 did not include the diagnosis of occipital neuralgia and the non-medical assessment specifically noted that the CI’s change of occupation duties were for the inability to fulfil the lifting (no greater than 10 pounds) and moving requirements as a nurse.

At the MEB examination the CI endorsed right-sided head pain that affected the area of the skin behind the ear in the distribution of the lesser occipital nerve. The pain was described as episodic and brief and could occur one or more times daily. The pain was spontaneous and would last for ‘…a few seconds, and then abate.”  A brief PE was normal.

At the VA examination, the CI endorsed an intermittent burning pain and abnormal sensation on the right side of her face. Additionally, she endorsed facial twisting and deformity, which lasted 3 to 5 seconds. The PE did not reveal any abnormalities within the head and nervous system. Additionally, with regards to activities of daily living, the provider documented, “…[CI] is able to brush her teeth, cook, shower, shop, dress herself, and drive a car. At times she has difficulty walking, climbing stairs, gardening, vacuuming, taking out the trash, and pushing a lawnmower.”

Panel members agreed that although there were subjective complaints of right-sided superficial head pain, the evidence of normal examinations coupled with the brief duration of symptoms, as well as the CI’s ability to continue driving, did not provide a preponderance of evidence  that

the occipital neuralgia condition was separately unfitting and therefore, the condition could not be recommended for additional disability rating.

BOARD FINDINGS: In the matter of the right C-8 radiculopathic pain and cervicalgia conditions and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the right-sided occipital neuralgia condition and IAW VASRD §4.124, the panel recommends no change in the PEB adjudication. In the matter of the chronic low back pain, the panel agrees it was unfitting and recommends a disability rating of 20%, coded 5099-5003 IAW VASRD §4.40. There are no other conditions within the panel’s scope of review for consideration.

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5099-5003	20%	

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