RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:XXXXXXXXXXXXXXXX	CASE:  PD-2017	-0502	1
BRANCH OF SERVICE:  NAVY	SEPARATION DATE: 20060331
SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E6, Wardroom/Galley Supervisor, medically separated for “continued lumbago, status post L4-5 fusion for chronic back pain” with a disability rating of 20%.
CI CONTENTION: The back condition continues to worsen, affecting his career and daily life activities. 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 - 20060201	VARD - 20060905	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Continued Lumbago, Status Post L4-5 Fusion for Chronic Back Pain	5241	20%	Degenerative Disc Disease, L4-5, Status Post Fusion	5243-5241	10%	20060713	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 40%	

ANALYSIS SUMMARY:

Low Back Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent an L4-5 laminectomy and interbody fusion in November 2004, followed by hardware removal in May 2005. Post-operative provider entries documented normal neurological examinations and the absence of complications. There was no record of any significant range of motion (ROM) limitation, and a physical therapy entry noted flexion to toes (grossly normal). There was documentation of a normal gait, and no evidence of an abnormal spinal contour or incapacitating episodes. Lumbar spine X-rays demonstrated normal alignment and some degenerative changes.

The 29 August 2005 MEB NARSUM examination, 7 months prior to separation, noted that the CI had “improved significantly,” but still complained of baseline pain rated at 2/10, which was exacerbated to 6/10 by prolonged standing or lifting. The physical examination recorded a normal gait, some “peri-incisional soreness,” and normal neurological findings (5/5 motor, intact

sensory, symmetric reflexes). The examination did not record ROM measurements, made no mention of tenderness, spasm or guarding, and did not discuss spinal contour.

At the 13 July 2006 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported intermittent low back pain that prohibited running, prolonged standing, and heavy lifting. The physical examination recorded a normal gait and spinal contour with “mild” tenderness, but no spasms or abnormal neurological findings. Measured ROM showed flexion to 85 degrees (normal 90) and combined ROM of 160 degrees (normal 240), with painful motion but no ROM degradation after repetition.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the low back condition 20%, coded 5241 (spinal fusion). The VA rated the low back condition 10%, dual coded 5243-5241 (intervertebral disc syndrome-spinal fusion), based on the C&P examination and citing VASRD §4.71a spine rating criteria. Panel member agreed that there was no VASRD spine criterion in evidence that would support a rating higher than the PEB’s 20%, and there was no documentation of 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 concluded there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.

BOARD FINDINGS: In the matter of the low back 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 that there be no modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

2	PD-2017-05021

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

IN REPL Y REFER TO :
1850
CORB: 003
10 Sep 20

From: Director, Secretary of the Navy Council of Review Boards To:

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) Ref:	(a) DoDI 6040.44
1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation to the Department of the Navy on 13 Aug 2020 for appropriate action.

2.	On 27 August 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR ofno change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.