RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXXXXX	CASE: PD-2017-04475
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20061108

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Motor Transport Operator, medically separated for “chronic back pain, status post L5-S1 fusion,” with a disability rating of 10%.

CI CONTENTION: “They gave me the lowest rating possible regardless of my condition.” He also requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).

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 - 20060918	VARD - 20070302	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain, Status Post L5-S1 Fusion	5241	10%	Degenerative Disc Disease of Lumbar Spine, Postoperative Fusion of L5-S1	5242	20%	20070216	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:

Chronic Back Pain. According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent back surgery in December 2004 for posterior spinal fusion of L5-S1 with retained hardware. On 18 April 2005, X-rays showed no change in the alignment of the hardware, and bone graft material was identified within the L5-S1 intervertebral disc space.

The 15 June 2006 MEB physical therapy (PT), 5 months prior to separation, revealed repetitive thoracolumbar spine flexion to 40 degrees (normal 90) and combined range of motion (ROM) of
105  degrees  (normal  240),  with  painful  motion.     The  6  September  2006  MEB     NARSUM

examination, 2 months before separation, noted CI complaints of progressively worsening back pain with muscle spasms. He reported back pain with intermittent numbness and tingling down the right leg, which was aggravated by strenuous activity. Physical examination showed a well- healed surgical incision, bilateral paraspinous tenderness, and mild muscle spasms. Thoracolumbar spine ROM was not addressed.

At the 16 February 2007 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported back pain aggravated with prolonged sitting, standing, bending, stooping or sudden movement. Physical examination revealed a normal gait, and repetitive thoracolumbar spine flexion was to 50 degrees with a combined ROM of 150 degrees; painful motion was elicited.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, coded 5241 (spinal fusion), citing pain-limited and localized tenderness. The VA rated the back condition 20%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing limitation of flexion. 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 on the MEB PT and VA examinations proximate to separation. There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that 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 back condition, coded 5241.

BOARD FINDINGS: In the matter of the back 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	
Chronic Back Pain, Status Post L5-S1 Fusion	5241	20%	

The following documentary evidence was considered:

	PD-2017-04475
AR20190012187, XXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXX

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

	PD-2017-04475