RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXX	CASE:  PD-2017-04808
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20091127

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Cardiopulmonary Lab Journeyman, medically separated for “chronic low back pain status post L4-5 fusion and epidural injections” with a disability rating of 20%.

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’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 - 20090427	VARD - 20091009	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5241	20%	Degenerative Disc Disease, Lumbar Spine Status Post Fusion	5010-5241	10%	20090818	
Major Depressive Disorder	Cat II 	Major Depressive Disorder	9434	30%	20090810	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:

Chronic Low Back Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent an L4-5 fusion in March 2008 due to an L5-S1 disc herniation with bilateral neural foraminal stenosis.  Despite surgery, she continued to have chronic pain.  During the 29 October 2008, MEB physical therapy examination, 13 months prior to separation, repetitive spine range of motion (ROM) showed flexion to 45 degrees (normal 90); painful motion was not addressed.  The 10 December 2008 MEB NARSUM examination, 11 months before separation, noted complaints of continued back pain despite surgery.  The examiner did not address gait, posture, tenderness, spasms or ROM, but motor strength, sensation and reflexes were within normal limits.  At emergency room visit on 3 March 2009, 9 months prior to separation, muscle spasm and severely limited back ROM was documented.

At the 18 August 2009 VA Compensation and Pension (C&P) examination, 3 months before separation, the CI reported constant lumbosacral pain with stiffness, weakness, muscle spasms and daily radicular pain going down the back of the thighs into the legs.  Flare-ups occurred 2-3 times a week, and were aggravated by any type of physical activity or standing for long periods; and she felt the surgery had made her back worse.  Physical examination showed a normal gait and posture, no muscle spasm, and tenderness present. Thoracolumbar flexion was 75 degrees and combined ROM was 180 degrees (normal 240), with painful motion.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 20%, coded 5241 (spinal fusion).  The VA rated the back condition 10%, dual coded 5010-5241 (arthritis, due to trauma-spinal fusion) based on the C&P examination, citing limitation of flexion or combined ROM.  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 physical therapy examination.  There was no evidence of intervertebral disc syndrome that resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate VASRD formula.  After due deliberation, considering all of 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 low back condition.  

Contended PEB Condition:  Major Depressive Disorder.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement.  At a 6 May 2009 psychiatric follow-up appointment, 7 months prior to separation, the CI reported feeling much better and completely different after starting medications, with others also noticing an improvement in her mood.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended major depressive disorder, the panel recommends no change from the PEB determination as not unfitting.  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:

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Dear XXXXXXXXXX

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-04808.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.