RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03428
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091115

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Animal Care Specialist, medically separated for “low back pain” with a disability rating of 20%.  

CI CONTENTION:  Her condition continues to 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 - 20090720	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Spinal Fusion L4-S1	5241	20%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Low Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent back surgery with fusion in 15 October 2008 for anterolisthesis of L4 on S1 with pars defect and right greater than left nerve root encroachment.  An MRI in April 2009 revealed post-surgical changes from L4-L5 with hardware in place.  

During the 30 April 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported low back pain with numbness and tingling in both feet.  Prolonged standing, sitting, lifting, or intimacy made the pain worse.  Physical examination showed decreased range of motion (ROM), especially during extension, and tenderness of the paraspinal muscles from L1-L5.  Thoracolumbar ROM measurements taken with a goniometer and performed by physical therapy on 28 May 2009 (5 months prior to separation) showed flexion of 75 degrees (normal 90) and combined ROM of 190 degrees (normal 240) after repetition, with painful motion.  

The 8 June 2009 MEB NARSUM examination, 5 months prior to separation, noted complaints of low back pain that had increased since surgery.  Physical examination showed the spine had a normal curvature.  Well-healed surgical scars were note. There was tenderness of the thoracolumbar spine, but no paraspinal muscle spasm.  Muscle strength was normal in all extremities. A July 2009 nerve conduction study showed normal motor and sensory function in the lower extremities.  There was no VA examination proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 20%, coded 5241 (spinal fusion), citing functional flexion between 30 and 60 degrees and an altered gait from guarding.  The panel concluded there was no evidence to support a rating higher than that adjudicated by the PEB.  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 back condition.  

BOARD FINDINGS:  In the matter of the 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.   

AR20180015267, 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.