RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX 	CASE:  PD-2017-04080
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081130

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Information Technology Specialist, medically separated for “spinal stenosis L5-S1” with a disability rating of 10%.   

CI CONTENTION:  Requested review of back condition, which continues to require treatment.  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 - 20081010	VARD - 20090925	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Spinal Stenosis L5-S1	5238	10%	L5-S1 Spondylosis and Lumbar Strain	5239	10%	20090925	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Spinal Stenosis.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI developed low back pain in October 2004 after heavy lifting.  Imaging (MRI, CT) demonstrated disc disease at L4-S1, with “very mild” stenosis and bilateral foraminal narrowing at L5/S1.  There was sporadic mention of radiating pain, but no motor or sensory symptoms.  Multiple neurological examinations were normal and surgery was not recommended.  There were numerous STR provider entries that documented grossly normal range of motion (ROM), with evidence of painful motion, and sporadic mention of non-specific ROM limitation.  There was ample documentation of a normal gait and spinal contour.  
The 21 August 2008 MEB NARSUM examination, 3 months prior to separation, documented “daily” non-radiating low back pain that was “aggravated with sitting for long periods, twisting, and turning.”  The physical examination recorded a normal gait, spinal contour and neurological findings, with no tenderness, guarding, or spasm.  Measured ROM showed flexion to 90 degrees (normal) with a combined ROM of 240 degrees (normal), specifying painful motion.

At the 21 October 2008 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI complained of constant pain radiating to the right leg, rated at 10/10, that was “elicited by physical activity and stress” (functional limitations not elaborated).  Physical examination noted a normal gait, spinal contour, and neurological findings, and no tenderness, guarding, or spasm.  Measured ROM revealed flexion to 85 degrees and a combined ROM of 225 degrees, with painful motion.  The examiner stated that pain with repetition would “additionally limit the joint function by 10 degrees,” but the panel agreed that was too non-specific to support a DeLuca deduction.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the lumbar spine condition 10%, coded 5238 (spinal stenosis), citing painful motion (referencing VASRD §4.59).  The VA also rated the condition 10%, coded 5239 (spondylolisthesis or segmental instability), based on the C&P examination, citing the applicable VASRD §4.71a spine criteria.  Panel members agreed that a 10% rating, but no higher, was justified for painful motion in addition to the 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) that was reported in the pre-separation C&P 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.  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 lumbar spine condition.  

BOARD FINDINGS:  In the matter of the lumbar 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.  

PD-2017-04080

AR20190012027, XXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXX

	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.

PD-2017-04080