RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX	CASE:  PD-2017-04979
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090311

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Wheeled Vehicle Mechanic, medically separated for “spinal fusion of the cervical spine at C5-C6 and C6-C7” 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 - 20081120	VARD - 20090908	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Spinal Fusion of the Cervical Spine at C5-C6 and C6-C7	5241	20%	Cervical Spine Degenerative Disc Disease Status Post Fusion (Claimed as Spinal Injury)	5003-5242	10%	20090806	
Adjustment Disorder with Mixed Anxiety and Depressed Mood	Not Unfitting	Post Traumatic Stress Disorder (PTSD), with Depression	9411	30%		
Gastroesophageal Reflux Disease		Gastroesophageal Reflux (Claimed as Acid Reflux)	7399-7346	0%		
Bilateral Hearing Loss		No VA Placement	
Minimal Osteoarthritis		No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Cervical Spinal Fusion.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent cervical spine surgery with C5-C6 and C6-C7 anterior decompression and fusion in August 2007 for herniated discs and myelopathy.  Cervical spine ROM measurements performed by physical therapy on 20 February 2008, (13 months before separation) showed flexion of 20 degrees (normal 45) and combined ROM of 120 degrees (normal 340), after repetition and limited by pain.  

The 5 June 2008 MEB NARSUM examination, 9 months prior to separation, noted CI complaints of neck pain.  Physical examination noted neck (anterior approach) surgical scar approximately 4 cm in length that was in a transverse orientation to the neck.  There was some slight weakness noted on the right versus the left for the C5 and C6 distribution, although it was not really perceptible on grip strength.  The final diagnosis from the MEB examiner was “neck pain secondary to decompression, C5 through C7, with surgical repair.”  There were no range of motion (ROM) measurements documented in the examination.  

At the 6 August 2009 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported neck pain and tingling in the right arm.  Physical examination showed normal posture and gait.  Cervical flexion was to 45 degrees and combined ROM was 270 degrees after repetition and limited by pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the cervical spine condition 20%, coded 5241 (spinal fusion), citing forward flexion to 20 degrees and combined ROM of 122 degrees.  The VA rated the cervical spine condition 10%, dual coded 5003-5242 (degenerative arthritis of the spine), based on the STR and C&P examination, citing pain and limited ROM.  Panel members agreed that based on the PT examination (noted on the PEB DA Form 199), a 20% rating, but no higher, was justified for limitation of flexion (greater than 15 degrees but not greater than 30 degrees) and combined ROM (not greater than 170 degrees).  The panel noted that the VA examination, which was more proximate to separation, documented cervical spine ROM consistent with a 10% rating.  Although the CI was diagnosed with intervertebral disc syndrome, there was no documentation of incapacitating episodes which would provide for a higher rating under that formula.  The panel concluded there was no evidence to support a rating higher than that adjudicated by the PEB.  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 cervical spine condition.  

Contended PEB Conditions:  Adjustment Disorder with Mixed Anxiety and Depressed Mood, Gastroesophageal Reflux Disease (GERD), Bilateral Hearing Loss (HL), and Minimal Osteoarthritis.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  The contended GERD, bilateral HL, and osteoarthritis were not profiled or implicated in the commander’s statement, and did not fail retention standards.  The contended adjustment disorder with mixed anxiety and depressed mood was a condition that did not constitute a physical disability IAW DoDI 1332.38, enclosure 5, and therefore the panel has no basis for recommending it as unfitting.  There was no performance-based evidence from the record that any of the contended conditions 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 adjudication for any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the cervical spine condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended gastroesophageal reflux disease, bilateral hearing loss, and minimal osteoarthritis, the panel recommends no change from the PEB determinations as not unfitting.  In the matter of the contended adjustment disorder with mixed anxiety and depressed mood, the panel agrees it cannot recommend it for additional disability rating.  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-2017-04979

XXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXX

	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.

Sincerely,					      

Enclosure

PD-2017-04979