RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02327
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091014

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Automated Logistics Specialist, medically separated for “spinal fusion of the cervical spine” with a disability rating of 20%.

CI CONTENTION:  “Was diagnosed as depressed instead of having PTSD [post-traumatic stress disorder] at time of PEB.  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 - 20090702	VARD - 20091029	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Spinal Fusion of the Cervical Spine	5241	20%	Cervical Spine Fusion	5241	20%	20090911	
Obstructive Sleep Apnea (OSA)	Not Unfitting	OSA	6847	50%	20090911	
Pes Planus	Not Unfitting	Bilateral Pes Planus	5276	0%	20090911	
Mild Anxiety	Not Unfitting	Mood Disorder	9435	30%	20090911	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:

Cervical Spine Fusion.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI suffered an atraumatic onset of neck pain in 2004 that resulted in surgery (C5-C7 fusion) in June 2008, 16 months before separation.  Post-operative provider entries in the STR documented the absence of any complications, the resolution of radicular complaints, and numerous normal neurological examinations.  There were several physical therapy (PT) entries after surgery that recorded cervical flexion to 30 degrees (normal 45), but noted improving range of motion (ROM), and later entries indicated that cervical ROM was grossly normal.  There was also documentation of normal spinal contour and gait and no incapacitating episodes after surgical recovery.  Post-operative X-rays demonstrated normal alignment and intact hardware.

The 17 June 2009 MEB NARSUM examination, 4 months prior to separation, noted CI complaints of daily neck pain, without radicular symptoms, that was aggravated by axial load bearing, running, and heavy lifting.  Physical examination (PE) recorded paraspinal tenderness without spasm, and a normal spinal contour and neurological findings (5/5 strength, intact sensory, symmetric reflexes).  Cervical spine flexion was to 20 degrees and combined ROM was 210 degrees (normal 340).  The 26 June 2009 MEB NARSUM addendum revealed goniometric repetitive flexion to 30 degrees and a combined ROM of 155 degrees, specifying painful motion.

At the 9 September 2009 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported daily neck pain, with new left arm radicular symptoms, that was aggravated by impact activities and forced rotation.  The PE recorded posterior tenderness, but normal spinal contour, gait, and neurological findings.  Cervical spine flexion was to 30 degrees with a combined ROM of 250 degrees, specifying painful motion.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the cervical spine condition 20%, coded 5241 (spinal fusion), citing limitation of flexion.  The VA also rated the cervical spine condition 20%, coded 5241, based on the C&P examination, citing limitation of flexion.  Panel members agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 15 degrees but not greater than 30 degrees), as reported on the MEB PT and VA examinations proximate to separation.  There was no other ratable criterion in evidence that would support a higher rating, and 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 cervical spine condition.

Contended PEB Conditions:  OSA, Pes Planus, and Anxiety.  The panel’s main charge is to assess the fairness of the PEB determinations that the contended conditions were not unfitting.  The CI was diagnosed with OSA in 2006 and treated with a nocturnal breathing assistance device (continuous positive airway pressure).  He underwent a PEB and was found fit for duty at that time, and remained on a P2 profile until separation.  There was STR documentation that symptoms were well-controlled with no daytime somnolence.  The CI had a chronic history of pes planus that was characterized as asymptomatic in the NARSUM with no STR entries indicating any active complaints or issues, and no requirement for a profile.  Provider entries in the STR documented a history of mood disorder from as early as 2004, but no evidence of suicidal ideation or other acute features, and no psychiatric hospitalizations.  There was no diagnosis of PTSD documented in the STR or by the VA after separation, and the MEB NARSUM listed a diagnosis of “mild anxiety controlled by Trazodone [mood stabilizer].”  There was no psychiatric profile throughout service, and the commander’s performance statement referred only to physical limitations with no note of mental health diagnosis, symptoms, or impairment.  This was corroborated by a performance evaluation contemporary with separation.

None of the contended conditions (OSA, pes planus, and anxiety) were implicated in the commander’s statement, neither the pes planus nor anxiety conditions were profiled, and none of the contended conditions failed retention standards.  There was no performance-based evidence from the record that any of the conditions 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 any of the contended conditions, so no additional disability ratings are recommended.
BOARD FINDINGS:  In the matter of the cervical spine condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended obstructive sleep apnea, pes planus, and anxiety conditions, the panel recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends that there be 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 20170227, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190012149, 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