RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXXX	CASE: PD-2017-02961
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20070727

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Tool and Equipment Technician, medically separated for “L5-S1 herniated disc status post [s/p] discectomy” with a disability rating of 20%.

CI CONTENTION: “Because issues (lumbar spine) are worse and veteran has trouble completing 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 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 - 20070419	VARD - 20071030	
Condition	Code	Rating	Condition	Code	Rating	Exam	
L5-S1 Herniated Disc…	5237	20%	Lumbar Spine Strain with Disc Disease; S/P Discectomy Claimed as Back Condition	5299-5237	20%	20070910	
Persistent Low Back Pain	Cat II					
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 40%	

ANALYSIS SUMMARY:

L5-S1 Herniated Disc. According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent back surgery in July 2006 for a herniated lumbosacral disc.   The    2 March 2007 MEB NARSUM examination, 5 months prior to separation, noted complaints of significant low back pain (LBP) and stiffness, with painful aggravation from running, heavy lifting, twisting and bending. The physical examination (PE) revealed a normal gait, tenderness about the lumbosacral muscle mass, and normal peripheral strength. Thoracolumbar range of motion (ROM) showed forward flexion to 70 degrees (normal 90) and a combined ROM of 200 degrees (normal 240), with painful motion.

At the 10 September 2007 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported constant LBP with stiffness, soreness and spasms. He also had occasional flare-ups precipitated by prolonged sitting, as over-exertion, lifting, bending and twisting, but denied periods of incapacitation or radicular symptoms. The PE revealed an antalgic

gait as well as lumbosacral spine tenderness and spasms. Spinal ROM measurements showed forward flexion to 70 degrees and a combined ROM of 185 degrees, with painful motion. A lumbar spine MRI was normal.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the low back condition 20%, coded 5237 (lumbosacral strain), and also listed persistent LBP as a related Category II condition (contributes to the primary unfitting condition but not separately ratable). Panel members agreed that the impairment from this diagnosis was properly subsumed under the overall rating for the herniated disc condition IAW §4.14 (avoidance of  pyramiding; more than one rating based on the same impairment is prohibited). The VA also rated the low back condition 20%, analogously coded 5299-5237, based on the C&P examination, citing the presence of muscle spasms or guarding severe enough to result in an abnormal gait or spinal contour. The panel agreed that a 20% rating, but no higher, was justified for muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, as reported on the VA C&P examination most proximate to separation. 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 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 low back condition.

BOARD FINDINGS: In the matter of the low back 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 20170327, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

2	PD-2017-02961

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN   REPLY  REFER  TO ,
1850
CORB: 003 20May20

From: 

Director, Secretary of the Navy Council of Review Boards 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW  (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr dtd 29 Oct 19

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy on 5 Mar 2020 for appropriate action.

2.	On 20 March 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR of no change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation  Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.