RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03918
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050628

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Motor Transport Operator, medically separated for “chronic neck pain” and “chronic low back pain (LBP),” rated 10% each, with a combined disability rating of 10%.   

CI CONTENTION:  “I am not being rated for mental health issues, including PTSD and major depression.”  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 - 20050415	VARD - 200508095	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5241	10%	Limited Motion, Cervical Spine, Status Post Discectomy	5241	20%	20060419	
Chronic LBP	5299-5242	10%	Degenerative Joint and Disc Disease, Lumbar Spine	5299-5242	10%	20050419	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Neck Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s chronic neck condition began in 2001.  No specific trauma or injury was reported.  The CI reported neck and left arm pain.  An MRI revealed degenerative disc disease (DDD) with a broad-based disc bulge at C5-6.  In June 2004, the CI underwent a discectomy with fusion providing some relief of the neck pain, however, arm and hand pain persisted.  Electrodiagnostic studies of the left upper extremity performed on 15 November 2004 were abnormal and consistent with a C5-6 radiculopathy or possibly a focal suprascapular neuropathy.  At the 5 August 2004 physical therapy examination, 10 months prior to separation, physical examination showed cervical spine flexion at 70 degrees (normal 45) and combined range of motion (ROM) at 315 degrees (normal 340).  During the 25 January 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported neck pain.  Physical examination revealed flexion at 45 degrees and combined ROM was not calculable.  There was no muscle spasm.  The MEB NARSUM examination the following day noted complaints of neck pain more severe than prior to his surgery with pain levels reaching 10/10 at the base of his skull and in the occipital area.  Physical examination showed decreased ROM with flexion at 45 degrees and combined ROM at 200 degrees.  Tenderness was noted over the cervical spine and paravertebral muscles.  Motor strength was normal and symmetrical.  

At the 19 April 2005 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported constant neck pain.  Pain levels were reported at 5/10 with pain elicited by physical activity and stress.  The CI reported at the time of pain he could function with medication.  He also reported 30 days of incapacitation in the past year with physician- recommended bed rest.  Physical examination showed a normal gait and evidence of radiating pain on movement and muscle spasm.  Tenderness was present and no ankylosis was noted.  Flexion was 25 degrees and combined ROM was 220 degrees with painful motion; with repetitive use ROM was additionally limited by pain, weakness, lack of endurance, with pain as the major functional impact.  There was no additional loss of cervical spine motion in degrees provided.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB and the VA rated the chronic neck condition 10% and 20%, respectively, both coded 5241 (spinal fusion). The PEB cited ROM limited by pain. The VA based the rating on the C&P examination, citing limitation of motion resulting in forward flexion of the cervical spine greater than 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 VA examination, the most proximate to separation.  The CI was diagnosed with intervertebral disc syndrome (IVDS), however, there was no evidence of incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition.  The CI reported 30 days of bedrest at the C&P examination, but there is no documentation of physician-prescribed bedrest in the STR.  Periods of convalescence from surgery are not incapacitating episodes for the purposes of rating under the VASRD general spine rules.  There was therefore no higher than a 20% rating supported for the neck condition.  

Chronic LBP.  According to the STR and MEB NARSUM, the CI had a history of LBP and numbness of his left leg and foot.  An MRI in January 2004 showed mild DDD at the L5-S1 level with a broad-based disc bulge and prominent facet joints causing mild bilateral neuroforaminal narrowing.  No surgery was recommended in March 2004.  The CI was undergoing treatment of the cervical DDD during this time as discussed above.  A repeat MRI in November 2004 was unchanged and a series of lumbar spine injections were undertaken.  The MEB NARSUM examination noted complaints of pain in the back and left leg rated at 8/10 continuously with bursts of 10/10 resulting from twisting and bending.  Physical examination showed flexion at 45 degrees (normal 90) and combined ROM at 110 degrees (normal 240).  There was paravertebral tenderness with some spasm bilaterally from T12 to S1.  

At the C&P examination the CI reported constant LBP that radiated to the left lower extremity.  Pain levels were reported at 5/10 with pain elicited by physical activity and stress but that he could function with pain medication; the condition had not caused incapacitation.  Physical examination showed a normal gait and there were no muscle spasms or tenderness or complaint of radiating pain on movement.  Bilateral straight leg raise testing was negative.  Flexion was 90 degrees with combined ROM at 240 degrees.  There was no additional limitation of motion due to pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB and the VA each rated the chronic low back condition 10%, analogously coded 5299-5242 (degenerative arthritis of the spine).  The PEB cited ROM limited by pain.  The VA rating was based on the C&P examination, citing pain with motion due to degenerative disease in the lumbar spine.  There was no limitation of thoracolumbar spine motion to support a 10% rating under the General Rating Formula for Diseases and Injuries of the Spine at the VA examination, the most proximate examination to separation, and the examination did not note the presence of painful motion, muscle spasm, guarding, or localized tenderness.  There was no evidence of additional functional loss after repetitive use.  There was no evidence of lumbar IVDS which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate VASRD formula.  There was therefore no higher than a 0% rating supported for the low back condition.  After deliberations, the panel’s rating recommendations of 20% for the neck condition and 0% for the low back condition result in the same overall combined rating of 20% as the PEB and provide no ratings benefit to the CI.  Therefore, no change to the PEB adjudications of the neck and low back conditions is recommended.  

BOARD FINDINGS:  In the matter of the chronic neck condition and IAW VASRD §4.71, the panel majority recommends no change in the PEB adjudication.  In the matter of the chronic low back 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

AR20190010907, XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXX:

	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.