RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03444
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20051128

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Health Care Specialist, medically separated for “chronic low back pain” with a disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  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 - 20050927	VARD - 20060105	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Degenerative Disc Disease, Lumbar Spine	5243	10%	STR	
			Radiculopathy, Left Lower Extremity	8720	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in 2002 without trauma or injury.  An MRI showed mild broad-based disc bulges at L4-5 and L5-S1 with an annular tear that was focal and central to L4-5.  A nerve conduction study (EMG/NCV) revealed L-5 lumbar radiculopathy on the left side and there was some evidence of a mild sensory neuropathy of the feet of “questionable significance.”  

At the 16 September 2005 MEB NARSUM examination, 2 months prior to separation, the CI reported constant 5/10 low back pain.  She reported that at times she would have numbness and tingling that would go down from her left buttock around the outside of the left thigh to the knee and down the front of the leg.  She also reported occasional sharp, stabbing pains in the same distribution.  Her pain was much worse with vigorous exercise or prolonged standing, by going up and down stairs or when trying to walk over uneven terrain.  She was unable to perform any impact activities due to the increase in pain.  Bending at the waist and squatting caused increased pain.  The neurosurgical consult deemed surgical intervention not appropriate.  On examination, gait was slightly antalgic, but she could heel and toe walk without difficulty and there was marked tenderness but no muscle spasms.  Spinal contour was not addressed.  Straight leg raise testing was positive at 45 degrees on both sides, but did not increase with dorsiflexion.  Pain was referred to her lower back and left buttock.  There were no skin or neurosensory changes observable in either lower extremity and her reflexes were intact.  Goniometric thoracolumbar range of motion (ROM) testing showed flexion of 70 degrees (normal 90) and combined ROM was 170 degrees (normal 240) with pain in almost all planes of motion.    

On 24 October 2005, a provocative discography and fluoroscopy was positive for intervertebral disc pathology.  The CI characterized her pain as piercing, stabbing, aching and tingling in nature, which originated in the lower lumbar spine and radiated to the left hip, buttock and left lower extremity.  Manometric testing at the L4-5 level was abnormal with evidence of the degenerated disc with fissures and clefts in the nucleus and annulus.  Manometric testing at the L5-S1 level was also abnormal.  The CI reported pressure in the center of her low back with radiation to the left greater than right hip and buttocks.  She reported pain that was identical to her typical clinical symptoms.  The pain intensity was severe and “horrible” with a numeric pain index of 10/10.  The neurosurgeon recommended an anterior fusion, but the STR showed no evidence of a surgical procedure ever occurring.  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 10%, coded analogously 5299-5237 (lumbar strain), citing pain limited motion with tenderness and no neurologic abnormality.  The VA also rated the back condition 10%, coded 5243 (intervertebral disc syndrome), based on the STR, citing pain limited motion with tenderness.  The VA also rated radiculopathy of the left lower extremity 0%, coded 8720 (neuralgia), citing no evidence to support mild incomplete paralysis.
 
The panel 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 combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the NARSUM examination.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate VASRD formula.  

The panel noted that the PEB rendered a de facto “not unfitting” determination for radiculopathy stating “without neurologic abnormality” and the CI contended this condition.  Electro-diagnostic studies supported some level of radicular nerve irritation or involvement, but physical examinations (PT and NARSUM) proximate to separation revealed no objective findings of radiculopathy that would impact duty performance.  The NARSUM examination described her gait as “slightly antalgic” but other examinations prior to and post-separation described her gait as normal.  She could do heel and toe walking without difficulty.  Although pain was referred to her lower back and left buttock, there were no skin changes and no neurosensory changes observable in either lower extremity.  There were normal motor, reflex and sensory examinations noted on the 8 August 2005 neurosurgical findings.  Muscle strength was recorded as “good” at the 13 July 2006 VA primary care examination.   While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation-specific activities.  There was no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  The panel therefore concluded that an additional disability rating was not justified on this basis.  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 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.  In the matter of the L-5 left radiculopathy condition, the panel agrees that it cannot recommend it for additional disability rating.  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 20160705, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008989, 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