RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02157
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an  active duty E3, Infantryman, medically separated for “lumbar degenerative disc disease [DDD],” and “[left] sciatic neuropathy,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  Requested review of his back condition, which now requires surgery, and sciatica in both legs. 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 - 20071107	VARD - 20080305	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar DDD	5299-5242	10%	DDD of the Lumbar Spine	5243	20%	20080219	
[Left] Sciatic Neuropathy	8520	10%	Left Knee Pain (Neuropathy)	8521-5260	NSC	20080219	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Lumbar DDD.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in December 2006 after a 55-gallon barrel fell on him.  He reported immediate low back pain (LBP) and right great toe numbness, but sought no treatment at that time.  He was seen a month later with the same complaints, but lumbar X-rays were normal.  An MRI in late February 2007 showed DDD with mild neuroforaminal (space through which the spinal nerves exit) narrowing at L5-S1.  
At an orthopedic spine consultation on 15 May 2007, 7 months prior to separation, the CI reported LBP with bilateral knee discomfort.  Physical examination showed a normal gait, no tenderness, and “mild symptom amplification.”  Range of motion (ROM) was flexion of 30 degrees (normal 90), extension of 10 degrees (normal 30) and right and left lateral rotation of 10 degrees (normal 30).  The provider noted pain with minimal axial loading and non-anatomic tenderness.  Lumbar spine X-rays were normal and an MRI showed no spinal canal stenosis, posterior encroachment or nerve root compression at any level.  Surgery was not recommended and the examiner commented, “I certainly cannot see anything structural to explain the amount of symptoms that he is having.” 

A neurosurgery evaluation on 24 May 2007 documented complaints of LBP and physical examination showed a normal gait and no neurologic abnormalities.  The neurosurgeon opined that the pain was musculoskeletal, and acknowledged that the CI’s orthopedic specialist did not recommend surgery.  A bone scan in June 2007 showed no spine abnormalities and a repeat MRI in July 2007 was unremarkable, with normal disc spaces, no disc herniation or protrusion, and no central canal or neuroforaminal stenosis.  At a neurosurgery visit on 3 August 2007, the CI complained of LBP with radiation to the bilateral lower extremities (LEs), and was referred to pain management.  On 21 August 2007, the pain specialist noted some left lumbar facet tenderness, with the majority of pain in the left sacroiliac joint area.   

The MEB physical therapy ROM study performed on 10 October 2007, 2 months prior to separation, showed flexion to 35 degrees with a combined ROM of 230 degrees (normal 240), and limitation of motion due to pain but not repetition.  No muscle spasm or guarding was noted.  During the 11 October 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), the CI reported LBP, and the provider documented an antalgic gait with lumbar muscle spasms and “limited ROM.”  The 18 October 2007 MEB NARSUM examination recorded CI complaints of LBP, and the physical examination largely mirrored the MEB examination results, which the MEB NARSUM examiner co-signed.  There was muscle spasm and back tenderness as well as pain with ROM, with the provider observing that the CI was “unable to get through the extremes of range due to pain in active ROM.”  A repeat MRI performed on 8 February 2008 revealed mild scoliosis, but was otherwise unremarkable with normal discs, vertebral canal, cord, and exiting nerve roots.  

At the 19 February 2008 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported constant LBP and flare-ups once a month for 1-3 days at a time.  The provider noted normal posture and gait.  There was lumbar spine tenderness, but no abnormal spinal curvature or sacroiliac joint tenderness.  Thoracolumbar ROM after three repetitions was flexion of 60 degrees and combined ROM of 210 degrees.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5242 (degenerative arthritis of the spine), citing pain limited motion.  The VA rated the back condition 20%, coded 5243 (intervertebral disc syndrome), based on the C&P examination, citing the VASRD rating criteria for a 20%  rating based on limitation of motion.  Members 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 ROM and VA examinations.  There was no evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate VASRD formula.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the back condition, coded 5299-5242.  

[Left] Sciatica Neuropathy.  Although the PEB listed “right” sciatic neuropathy as an unfitting condition, additional remarks referred to abnormal findings of left leg pain and mild weakness, as well as an electrodiagnostic study which was performed on the left LE.  Therefore, the panel concluded the sciatic neuropathy actually referred to the left LE and was simply a clerical error.  
According to the STR and MEB NARSUM, the CI’s left sciatic neuropathy began following the same back injury in December 2006 summarized above.  In April 2007, he reported the development of pain radiating to both LEs, but worse on the left.

The May 2007 orthopedic evaluation showed a normal gait, and examination maneuvers to elicit radicular pain were negative.  Motor strength, sensation and reflexes were normal and there was no muscle atrophy.  As noted above, the MRI showed no evidence of spinal canal stenosis posterior encroachment or nerve root compression at any level, and surgery was not recommended.  The neurosurgery examination 9 days later also showed normal gait, LE strength, sensation, and reflexes, and no evidence of radiculopathy.  

The CI sought another surgical opinion on 27 August 2007 and complained of pain radiating down the left LE to the lateral aspect of the foot.  Physical examination showed 4/5 strength during left foot dorsiflexion and plantar flexion as well as great toe dorsiflexion, and difficulty with single leg raising.  There was decreased sensation in the L5 distribution, but normal reflexes.  The examiner indicated there was a possible nerve stretch injury with no MRI evidence of a disc herniation or stenosis.  Electrodiagnostic studies on 18 September 2007 were normal, and a physical examination the same day showed normal LE strength, sensation and reflexes.

During the MEB examination, the CI reported pain that radiated down the left LE as well as lateral LE numbness.  Straight leg raise (SLR) testing was positive on the left, and sensation was decreased to light touch and pinprick in the L5-S1 distribution.  The CI was “unable” to execute left foot plantar or heel walk, but could toe and tandem walk.  An 31 October 2007 MEB addendum  referenced normal left LE electrodiagnostic studies but noted mild weakness of hip flexors graded 4+/5 (L1-L4 innervation), knee flexors graded 4/5 (S1) and ankle dorsiflexors and plantar flexors graded 4/5 (S1). 

At the C&P examination the CI reported intermittent radiating pain down the legs, left greater than right.  Physical examination showed normal gait, motor strength and reflexes.  He was able to heel, toe, and tandem walk and perform a shallow squat without difficulty.  The SLR test was negative bilaterally and the provider stated, “there are no objective findings of radiculopathy or polyneuropathy at this time.” 
 
The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left sciatic neuropathy 10%, coded 8520 (paralysis of sciatic nerve), citing mild incomplete paralysis.  The VA found the left sciatic neuropathy to be not service connected (NSC) and did not rate it.  Members observed that the CI reported radiating pain to both LEs beginning in April 2007, 5 months after the initial injury.  Examinations by an orthopedic spine surgeon and a neurosurgeon in May 2007 were normal with two MRIs indicating no need for surgery.  In August 2007, the CI complained of continued radicular symptoms of both LEs and the surgeon recorded findings in the left L5 distribution.  However, left LE electrodiagnostic studies in September 2007 were normal.  The MEB examinations documented decreased sensation in the left S1 nerve root distribution and motor weakness that involved multiple lumbar nerve roots rather than a single nerve root distribution.  At the C&P examination, the CI reported intermittent radiation of pain down the LEs, but no neurological abnormalities were noted.  The panel agreed that while the MEB examinations recorded a left LE neuropathy, there was otherwise no support for the diagnosis of a left or right extremity neuropathy in the record.  Radiating pain from the low back is subsumed in the panel’s 20% rating recommendation above IAW VASRD §4.71, and thus the panel finds no basis for a disability rating for neuropathy.  However, because the panel may not change a PEB diagnosis or recommend a condition as not unfitting if the PEB adjudicated it as unfitting, a 0% rating for the left sciatic neuropathy condition is recommended.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the left sciatic neuropathy, coded 8520. 

BOARD FINDINGS:  In the matter of the lumbar degenerative disc disease and IAW VASRD §4.71a, the panel recommends a disability rating of 20%, coded 5299-5242.  In the matter of the left sciatic neuropathy and IAW VASRD §4.124a, the panel recommends a disability rating of 0%, coded 8520.  There are no other conditions within the panel’s scope of review for consideration.  The above recommendations do not result in a change to the overall PEB rating.  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 20170313, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR, 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