RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-03251 BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20080215

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Electronic Maintenance Technician, medically separated for “cervical spondylosis s/p C5-6 fusion” with a disability rating of 20%.

CI CONTENTION: “Neck pain radiates into left shoulder.” The complete submission is 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 - 20070712	VARD – 20080319	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Spondylosis S/P C5-6 Fusion	5241	20%	Status Post C5-6 Cervical Decompression and Fusion	5242	20%	20070611	
Cervical Radiculopathy	Cat II					
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 60%	
	
ANALYSIS SUMMARY:

Cervical Spondylosis Status Post (S/P) C5-6 Fusion. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s neck pain condition began in 1998 following a “whiplash” type injury. Chiropractic manipulations and physical therapy (PT) did not provide any degree of pain relief. An MRI revealed degenerative changes of the lower cervical spine with narrowing of the nerve exiting canals. In August 2006, the CI underwent a cervical (C5-6) surgical discectomy and fusion. Despite surgical intervention and aggressive rehabilitation, the CI continued to endorse neck pain with extension into both sides of the upper back. Electro-diagnostic studies performed to rule out entrapment of cervical nerves were normal.  At the 28 March 2007 MEB NARSUM examination, 10 months prior to separation,   the

CI’s chief complaint was documented as, “chronic cervical pain without significant arm pain or numbness.” The physical examination (PE) revealed normal cervical flexion and a combined directional range of 225 degrees (normal 340). Bilateral upper extremities revealed normal strength.

At the 11 June 2007 VA Compensation and Pension (C&P) examination, 8 months prior to separation, the CI reported pain involving the midline as well as the left side with some radiation into the right posterior neck and radiation in the right and left upper back region. The PE revealed painful cervical spine flexion to 25 degrees that extended into the upper back. The combined cervical ROM was 185 degrees. The ROM was not additionally limited by pain, weakness, fatigue, or lack of endurance following repetitive testing or flare-up. Tenderness was present in the neck and upper back areas.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the cervical spondylosis condition 20%, coded 5241 (spinal fusion). The PEB also listed cervical radiculopathy as related diagnosis (Category II) condition. The VA rated the C5-6 cervical decompression and fusion condition 20%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing forward flexion of the cervical spine of 15 degrees but not greater than 30 degrees.

The panel 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 pre-separation VA examination. There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula. There was no associated unfitting radiculopathy for separate peripheral nerve rating. While the CI may have experienced radiating pain from the neck condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).” There was no objective evidence of a radiculopathy with functional impairments (such as weakness) that directly impacted fitness for duty. The panel therefore concluded that additional disability rating was not justified on this basis. 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 spondylosis condition.

BOARD FINDINGS: In the matter of the cervical spondylosis condition and IAW VASRD §4.71, 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:

2	PD-2017-03251

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 27 Jun 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 ofno 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.

Copy to: PDBR