RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03152
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040803

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Multi-Channel Transmission System Operator, medically separated for “cervical neck pain” with a disability rating of 20%.   

CI CONTENTION:  He requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20040329	VARD - 20041113	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Neck Pain	5241	20%	Status Post Interbody Infusion and Anterior Plates Stabilization C6- 7, Cervical Spine	5241	20%	20040716	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Cervical Neck Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI sustained a C6-7 herniated disc in March 2001 during a field training exercise and reported neck and left (non-dominant) upper extremity pain and numbness.  He continued to have pain after a full course of conservative treatment, and subsequently underwent a C6-7 cervical discectomy and fusion on 8 July 2002.  

At the 7 February 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 18 months prior to separation, physical examination showed a normal spinal contour without deformity and minimal cervical spine tenderness.  The 30 April 2003 MEB NARSUM examination, 15 months before separation, noted CI complaints of neck pain and intermittent left arm numbness.  Physical examination showed minimal cervical spine tenderness and normal neurological findings.  Cervical ROM tests revealed flexion to 40 degrees (normal 45), extension to 10 degrees (normal 45 degrees) and lateral flexion of 20 degrees (normal 45) bilaterally (lateral rotation was not measured so a combined ROM could not be determined).  Cervical spine X-rays showed an anterior plate with well-healed surgical fusion at C6-7.  

The CI non-concurred with the Informal PEB findings, and the MEB issued an addendum on 16 October 2003, 10 months prior to separation.  The examiner referred to 2 September 2003 electrodiagnostic studies which showed changes in the left tricep muscle consistent with the patient’s history of a “remote C7 radiculopathy,” and non-specific changes in the left bicep, possibly consistent with radiculitis of the C5 or C6 nerve root.  Cervical ROM, measured by physical therapy, showed active flexion to 10 degrees and a combined ROM of 150 degrees (normal 340); no further surgery was recommended.  

At the 16 July 2004 VA Compensation and Pension (C&P) evaluation, 2 weeks before separation, the CI reported his condition improved following surgery, but that he still experienced left side numbness affecting the left fourth and fifth fingers and inner aspect of the arm and forearm.  The examiner noted that “in general, he can sustain heavy physical activities without immediate distress.”  Physical examination showed a normal posture, gait and spinal curvature.  Cervical ROM was flexion of 20 degrees and a combined ROM of 125 degrees, without pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the cervical condition 20%, coded 5241 (spinal fusion).  The VA also rated the cervical condition 20%, coded 5241, based on the C&P examination, citing forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees.  Members agreed that a 20% rating was justified for limitation of cervical flexion (greater than 15 degrees but not greater than 30 degrees).  Although the MEB addendum noted active cervical flexion of 10 degrees, the C&P examination was most proximate to separation, and accordingly, the panel gave it greater probative weight.  The CI did have intervertebral disc syndrome, however, there was no documentation of 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 cervical spine condition.   

BOARD FINDINGS:  In the matter of the cervical spine 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 20170216, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180008979, 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