RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02948
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050405

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E7, Infantryman, medically separated for “chronic back pain” with a disability rating of 10%.  

CI CONTENTION:  The back condition continues to worsen and negatively impact daily activities.  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 - 20050301	VARD - 20050902	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain 	5241	10%	Residuals, L4-S1 Fusion	5239	20%	20050505	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60% 	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI suffered from degenerative disc disease and bilateral L4 spondylolysis (defect or stress fracture) and underwent L4-S1 lumbar interbody fusion utilizing cages, screws, bone morphogenetic proteins (growth factors) and an autograft in July 2003.  An MRI on 3 December 2004 noted a lumbar spinal fusion, status post lumbar disc cage surgery with an increase in granulation tissue compatible with post-surgical change, no compromise to the foramina and mild exaggerated lumbar lordosis.  
During the 5 January 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported chronic low back pain (LBP).  Physical examination revealed lumbar spine tenderness, and thoracolumbar active range of motion (ROM) testing showed flexion of 75 degrees (normal 90); no additional ROM measurements were noted.  At the 7 January 2005 MEB NARSUM examination, neurological findings were normal but gait, posture, tenderness, spasm, painful/repetitive motion, and ROM measurements were not mentioned.  

At the 5 May 2005 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported continued LBP despite surgical intervention. Physical examination showed a normal gait and station, and a well-healed 8-inch scar in the lumbar area with no evidence of major muscle group atrophy.  Thoracolumbar active ROM measurements showed flexion of 70 degrees and combined ROM of 145 degrees (normal 240).  

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 limitation of motion with tenderness.  The VA rated the back condition 20%, coded 5239 (spondylolisthesis or segmental instability), based on the C&P examination, citing muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour.  Members 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/or combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the MEB and VA C&P examinations.  The panel noted that a 10% rating was also justified for localized lumbar tenderness as documented by the PEB.  Although the VA Rating Decision cited muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, the C&P examination reported a normal gait and station, with no muscle spasms or guarding; thus the next higher 20% rating 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 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 chronic back pain condition.  

BOARD FINDINGS:  In the matter of the chronic back pain 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.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170401, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record  

AR20180008805, 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