RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX  	CASE:  PD-2017-04103
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071026

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E6, Civil Affairs Specialist, medically separated for “cervical fusion C5-6” with a disability rating of 10%.  

CI CONTENTION:  In addition to his neck condition, the CI also requested review of other conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20070828	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Fusion C5-6 	5241	10%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Cervical Fusion C5-6.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s neck condition began in December 2005 after his vehicle was struck by an IED while deployed.  X-rays were normal, but an MRI revealed moderately severe canal stenosis at C5-C6 with probable left sided nerve impingement.  Electrodiagnostic testing of the left upper extremity was normal.  The CI was evaluated in neurosurgery on 15 November 2006 and surgery was not recommended.  However, the CI pursued care in the civilian sector and a C5-6 discectomy and fusion was performed on 5 December 2006 along with decompression of the bilateral foramina.  In follow up on 26 January 2007, the left arm pain had resolved.  

During the 14 June 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, there was no spasm.  Cervical spine range of motion (ROM) testing showed, after rounding, flexion of 45 degrees (normal) and combined ROM of 265 degrees (normal 340).  The neurological examination was normal.  The cervical spine ROM measurements performed by physical therapy on 19 June 2007 showed flexion of 45 degrees and combined ROM of 245 degrees, after repetition.  Motion was limited mechanically and by pain.  The 30 July 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of chronic neck pain.  Physical examination showed a normal gait without abnormal spinal contour, muscle spasm or guarding noted on examination.  Reflexes were normal.  There was no VA Compensation and Pension (C&P) examination proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5241 (spinal fusion), citing a mechanical limitation from the fusion.  The VA rated the neck condition 0%, also coded 5241, based on the STR, noting that the CI had failed to show for the C&P examination.  The panel agreed that a 10% rating, but no higher, was justified for combined ROM (greater than 170 degrees but not greater than 335 degrees), as reported on the MEB and NARSUM examinations proximate to separation.  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 neck condition.  

BOARD FINDINGS:  In the matter of the neck 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.  

The following documentary evidence was considered:

AR20180016626, 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.