RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-04308 BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20050201

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E5, Field Medical Technician, medically separated for “failed laminectomy syndrome” 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 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 - 20050118	VARD - 20050818	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Failed Laminectomy Syndrome	5241	10%	Status Post Lumbar Laminectomy/ Discectomy and Fusion	5243	40%	20050223	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 60%	

ANALYSIS SUMMARY:

Failed Laminectomy Syndrome. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent L5-S1 laminectomy and discectomy procedures on two occasions, the first in 1998 and the second in January 2004. In September 2004, he had an L5-S1 fusion for 20% back pain and 80% left lower extremity pain that was not responsive to activity modification, medications, physical therapy, or multiple modalities. The 29 November 2004 MEB NARSUM examination, 4 months prior to separation, recorded complaints of 75% back pain and 25% left leg ache in an S1 distribution. The examiner noted a normal gait and “full” range of motion (ROM) as “defined by the Federal Register Volume number 68, dated Wednesday 27 AUG 2003.” Lumbar radiographs the same day showed early bony growth posterior to the anterior column structural graft placed during the fusion surgery, and no evidence of screw or rod loosening of the bilateral pedicles bilaterally at L5 and S1. An MRI showed some slight posterior disc protrusion at L4-5 without impingement on the neural elements as well as evidence of the L5-S1 fusion taking place. During the 11 December 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), the CI reported lower back pain and frequent spasms, and the examiner wrote “has back brace.”

At the 23 February 2005 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported low back pain that radiated to the left lower extremity with occasional numbness and tingling sensation. Physical examination showed normal gait and posture, but straightening of the lumbar lordosis as well as paraspinal muscle spasm at L3-4, L4-5 and L5-S1. Thoracolumbar ROM measurements showed flexion of 50 degrees (normal 90) and combined ROM of 170 degrees (normal 240), with painful motion.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the lumbar condition 10%, coded 5241 (spinal fusion). The VA rated the lumbar condition 40%, coded 5243 (intervertebral disc syndrome (IVDS)), based on the C&P examination, citing findings of objective evidence of painful thoracolumbar spine flexion limited to 50 degrees, paraspinal muscle spasm with straightening of the lumbar lordosis, and additional disability due to fatigue and lack of endurance. Panel members agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) as reported at the VA examination most proximate to separation. There was no evidence of IVDS which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate formula. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the lumbar condition, coded 5241.

BOARD FINDINGS: In the matter of the lumbar condition, the panel recommends a disability rating of 20%, coded 5241 IAW VASRD §4.71a. There are no other conditions within the panel’s scope of review for consideration.

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Failed Laminectomy Syndrome	5241	20%	

The following documentary evidence was considered:

2	PD-2017-04308

DEPARTMENT OF THE NAVY
SECRETARY OF TI-!E NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN REPLY REFER TO:
1850
CORB:003
12 Oct 20

From: To:

Subj:

Ref:

Director, Secretary of the Navy Council of Review Boards 

PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

(a) DoDI 6040.44
(b)	PDBR ltr of 29 Nov 19
(b)	

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation to the Department of the Navy for appropriate action.

2.	On 7 October 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) took action in your case by accepting the recommendation of the PDBR. Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Department of the Navy Physical Evaluation Board (PEB) from 10% to 20% without re-characterization of your discharge.

3.	For your information, since all disability ratings from 0% to 20% qualify for disability severance pay, the above stated increase will not result in your entitlement to additional compensation.

4.	The Assistant Secretary's determination, which represents final action in your case by the Department of the Navy, has been forwarded to the Navy Personnel Command for appropriate changes to your personnel records and notification to you upon completion.