RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02804
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20070205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Munitions Systems Journeyman, medically separated for “chronic low back pain status post L5-S1 decompression laminectomy with radiculopathy” with a disability rating of 10%.  

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 - 20061201	VARD - 20070706	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain… 	5243	10%	Intervertebral Disc Syndrome, Thoracolumbar Spine	5243	20%	20070309	
			Radiculopathy, Right Leg associated with…	8599-8520	10%	20070309	
			Radiculopathy, Left Leg associated with…	8599-8520	0%	20070309	
Hypertension	7101	Cat II	Hypertension	7101	10%	20070309	
Restless Legs Syndrome	8199-8108	Cat II	No VA Placement	
Tobacco Abuse	Cat III	No VA Placement	
Obesity	Cat III	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain Status Post L5-S1 Decompression Laminectomy with Radiculopathy.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s chronic back pain and right leg pain began in July 2003 in the absence of an injury or trauma.  Since August 2004 he had persistent pain.  An MRI dated 21 December 2004 demonstrated a right paracentral disc herniation likely affecting the right S1 nerve root within the lateral recess.  An MRI on 13 September 2005 demonstrated degenerative disc disease at L4/L5 and L5/S1, a disc bulge at L5/S1 contacting the right L5 nerve root, and a disc bulge at L4/L5 with spinal canal or neural foraminal compromise.  On 1 November 2005 the CI underwent back surgery, which included a fenestration procedure, excision of the right L5/S1 disc prolapse, and a thorough neurolysis of the right S1 root.  However, the CI still had residual pain.  An MRI on 18 April 2006 showed probable postsurgical changes at both the left L4/5 and right L5/S1 levels and no evidence of disc re-herniation or central spinal stenosis.  At the 5 May 2006 neurology visit the CI reported minimal improvement post-operatively and continued low back pain with radicular symptoms into the right leg; however, he denied numbness or weakness.  The CI walked with a slight limp on the right.  Motor strength was normal and normal sensation was present to touch and pin prick.  The examiner noted the CI was not missing work.  

The 14 August 2006 neurology examination, performed as part of the MEB 6 months prior to separation, noted complaints of continued low back pain with radiation into the right leg to the mid-calf.  His discomfort severity was 6-7/10 most of the time.  The CI denied numbness or weakness and reported he was not missing work.  Physical examination showed a slight limp on the right.  A repeat MRI showed no recurrent herniation.  No sensory examination abnormalities were noted on touch and pinprick.  Motor examination demonstrated no dysfunction.  X-rays revealed probable postsurgical changes at both the left L4/5 and right L5/S1 levels and no evidence of disc re-herniation or central spinal stenosis.  The examiner’s assessment was lumbar neuritis and a failed back syndrome.  Trunk range of motion (ROM) measurements performed by physical medicine on 3 November 2006, 3 months prior to separation, showed flexion of 65 degrees (normal 90) and combined ROM of 165 degrees (normal 240) after repetition.  

At the 9 March 2007 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported constant pain which traveled down the left leg to the knee, and down the right leg to the ankle.  Physical examination showed normal posture and gait.  There was tenderness over the paravertebral musculature of the lumbar spine, but no muscle spasm.  Straight leg raising tests were positive bilaterally (to determine nerve root irritation).  There was no motor weakness in the bilateral lower extremities, but mild loss of tactile sensation and vibratory sensation in the dorsum of the feet was evident.  Thoracolumbar range of motion (ROM) measurements showed flexion of 75 degrees and combined ROM of 225 degrees with painful motion noted.  The joint function of the spine was additionally limited after repetitive motion by pain, fatigue, and lack of endurance, and pain had the major functional impact.  The examiner stated “the above additionally limited the joint function by 24 degrees.”  There was a sensory deficit of the right dorsal foot and no motor weakness of the lower extremities.  Deep tendon reflexes were 2+ bilaterally.  There was no bowel, bladder, or erectile dysfunction.  The examiner’s diagnosis was intervertebral disc syndrome (IVDS), and the most likely involved peripheral nerves were the deep peroneal and sciatic nerves with no complications.  Subjective factors were numbness and radiating pain, while the objective factors were positive straight leg raising, decreased vibratory sense, and decreased tactile sense.  At the 17 December 2007 VA clinic appointment, 10 months after separation, physical examination noted back flexion to greater than 90 degrees, intact sensation and reflexes, and good extensor hallucis longus strength.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5243 (IVDS).  The VA rated the back condition 20%, coded 5243, based on the C&P examination, citing forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees.  The VA also rated right leg radiculopathy 10%, coded 8599-8520 (sciatic nerve, mild incomplete paralysis) citing an L5 sensory deficit and no motor weakness.  Left leg radiculopathy was rated 0%, coded 8599-8520, citing no evidence of incomplete paralysis.  

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the  neurology/MEB examination.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of IVDS with incapacitating episodes which would provide for a higher rating under that formula.

The CI had a herniated disc with radicular pain treated with surgery, and there were symptoms of radiating pain documented in the treatment records; however, examinations indicated normal strength, reflexes, and gait, and the sensory changes of the right lower extremity did not significantly affect his job.  The presence of functional impairment with a direct impact on fitness is the key determinant in the panel’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation-specific activities.  There was no evidence in this case that motor weakness existed to any degree in either the right or left lower extremity that could be described as functionally impairing.  The panel therefore concluded that an additional disability rating was not justified on this basis.  After due deliberation, considering all of 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.  

Contended PEB Conditions:  Hypertension, Restless Legs Syndrome, Tobacco Abuse, and Obesity.  The panel’s main charge is to assess the fairness of the PEB determination that the contended Air Force Category II hypertension and restless legs syndrome conditions and Category III tobacco abuse and obesity conditions were not unfitting.  Hypertension (BP 155/98) was noted on 5 May 2006 at which time the CI had moderate to severe low back pain.  The blood pressure was 148/92 on 14 August 2006 and 148/84 was noted on 24 October 2006 post pilonidal cyst excision.  The CI did not receive treatment for the hypertension.  The restless legs syndrome was felt to be a component secondary to spinal disease.  On 14 August 2006 the neurologist noted the restless legs syndrome was associated with lumbosacral radicular disease, and the CI failed with a dopamine agonist, gabapentin, and topiramate.  Obesity and tobacco abuse are conditions that do not constitute a physical disability.  The panel therefore has no reasonable basis for recommending any of the contended conditions as additionally unfitting for separation rating.  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 chronic low back pain condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended hypertension, restless legs syndrome, tobacco abuse, and obesity 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 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 20170422, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-02804.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

						Sincerely,

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings