RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXX	CASE: PD-2017-05108
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20050711

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Storekeeper, medically separated for “chronic pain syndrome with neck spasm” with a disability rating of 10%.

CI CONTENTION: “I am now unable to work or carry on a normal life like before. I stay depressed and want nothing to do with society. My condition is getting worse.” 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 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 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 – 20050404	VARD - 20050729	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Syndrome, With
Neck Spasm	5237	10%	
Spondylosis C3-C7 with T-1 Spinous Process Fracture and Cervicogenic Headaches	
5243-5237	
30%	
20050613	
Status Post T1 Spinous Process Fracture	Cat II					
Cervicogenic Headaches						
Cervical Radiculopathy with Neck
Spasms	Cat II	No VA Placement	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:

Chronic Pain Syndrome With Neck Spasms. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI hyperextended his neck after hitting his head on the roof of a truck in May 2003. He subsequently had continuous neck and shoulder pain, muscle spasm, and intermittent paresthesias of both arms. Prior to hitting his head, he had received orthopedic treatment for right shoulder impingement symptoms to include periodic shoulder injections. He was diagnosed with cervical disc disease with right radicular symptoms, and surgery was not recommended.

The 1 March 2004 MEB NARSUM examination noted the CI had a previous period of limited duty (LIMDU) for right-sided radicular symptoms, with a diagnosis of cervical disc disease. Physical

examination showed cervical neck muscle spasms bilaterally, with decreased range of motion (ROM) and intermittent radiating pain and paresthesias down the right arm, particularly with movement towards the right. A second 8-month LIMDU period was recommended. A cervical spine CT scan in June 2003 noted sclerotic margins on the spinous process of T1 which may have represented a developmental abnormality (unfused apophysis), but a non-united T1 spinous process fracture could not be ruled out. No other abnormality was noted. An MRI in August 2004 showed moderately extensive degenerative arthritis changes from C3-C7 with encroachment of the right neural foramen at C5-6, and of the left foramen at C6-7. The CI was treated by the pain clinic and neurology without sufficient improvement to return to full duty.

The 27 October 2004 MEB NARSUM, 9 months prior to separation, noted that the CI had been treated with multiple pain medications to include Botox injections (for muscle spasm). Physical examination showed rigidity and spasm in the bilateral paracervical muscles with decreased neck ROM, but normal gait and strength. Consideration of electrodiagnostic testing and neurosurgical consultation was raised, with a recommended referral to the PEB for final adjudication. During the 5 November 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), the CI reported “severe” neck pain and arm numbness if he “moved his neck too far.” The examiner noted that he held his head in approximately 10 degrees of flexion and had decreased extension and rotation due to pain. An undated (after 2 November 2004) MEB NARSUM addendum examination noted complaints of neck pain and limitation of motion. Physical examination showed left-sided neck pain, rated at 8/10, with spasm and trigger points at C7 and the paraspinal muscles in the upper thorax area. Cervical ROM was decreased, but gait was normal with sensation and other neurological findings intact.

At the 13 June 2005 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI reported constant neck pain and stiffness aggravated by any type of motion, as well as some radiation into the upper back. He also had associated occipital pain with dull, intermittent headaches 4-5 times per week that lasted for hours, but did not cause nausea, vomiting or visual changes. He reported slight dizziness when he had severe head or neck pain, and took a daily opiate pain medication. Physical examination showed that the CI could flex his neck to 10 degrees before “severe” pain occurred, and could not extend or rotate the neck more than 10 degrees in either direction without causing “extreme” pain.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated neck condition 10%, coded 5237 (cervical spine strain). The VA rated the neck and headache conditions 30%, dual coded 5243-5237 (intervertebral disc syndrome (IVDS)-cervical spine strain) based on the C&P examination, citing cervical spine flexion of 15 degrees or less. Panel members agreed that a 30% rating was justified for limitation of flexion not greater than 15 degrees as reported on the VA examination, which was the most proximate to separation and supported by findings in the STR, including the MEB examination. 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 30% for the neck condition, coded 5237.

Contended PEB Conditions: Status Post T1 Spinous Process Fracture, Cervicogenic Headaches, and Cervical Radiculopathy with Neck Spasm. The PEB listed the contended conditions as related Category II diagnoses, and the panel’s first charge is to assess whether any of them were reasonably justified as separately unfitting for rating consideration. In this circumstance, the Category II conditions are considered unfitting unless there is a preponderance of evidence that they are not unfitting.

The LIMDU report dated 1 March 2004 listed “cervical disc disease with right-sided cervical radiculopathy” and “cervicogenic headaches, secondary to cervical neck spasm.” The 27 October

MEB NARSUM also listed “cervical radiculopathy, with neck spasms” and cervicogenic headaches as causing the CI to fail retention standards. The final MEB NARSUM addendum listed “status post T1 spinous process fracture,” with nonunion and chronic pain syndrome, with neck spasm as causing the CI to fail retention standards. The non-medical assessment implicated neck pain and associated headaches as impairing the CI’s duty performance.

Status Post T-1 Spinous Process Fracture. Although this condition was listed on the MEB NARSUM addendum, the CT scan noted that the T1 findings may have been a developmental abnormality found at the time of the neck injury. Whether the finding was a non-united fracture of the spinal process or not, there was no evidence of residual disability that could be distinguished from the chronic pain and neck spasm condition, which was attributed to cervical spondylosis. The panel agreed the preponderance of evidence showed the status post T1 spinous process fracture was not separately unfitting apart from the primary unfitting condition and is appropriately adjudicated as a related Category II condition.

Headaches. The headache condition was listed on LIMDUs, implicated by the NMA and failed retention standards. Thus, panel members concluded that there was not a preponderance of evidence to overcome the presumption that this condition was reasonably considered separately unfitting and eligible for disability rating. The panel directed attention to its rating recommendation based on the above evidence. The VA did not provide a separate rating for the headaches, but subsumed them in the 30% rating of the cervical spine, coded 5237. Rating guidance under diagnostic code 8100 (migraine) is based on the frequency of “prostrating attacks” over the “last several months.” The VASRD does not further define prostrating attacks, however commonly accepted definitions include “utter physical exhaustion or helplessness” (Webster's New World Dictionary of American English), “complete physical or mental exhaustion” or “extreme exhaustion or powerlessness” (Dorland's Illustrated Medical Dictionary). Panel members carefully considered the frequency and nature of the CI’s headaches, including objective and corroborating subjective evidence, and agreed that there was no record of prostrating headache attacks averaging 1 in 2 months over the last several months to support a rating higher than 0%, coded 8199-8100. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the cervicogenic headaches, coded 8199-8100.

Radiculopathy. The right-sided radiculopathy condition was listed on LIMDUs, implicated by the NMA and failed retention standards, and panel members agreed there was not a preponderance of evidence to overcome the presumption that the right radiculopathy condition was reasonably considered separately unfitting. The panel directed attention to its rating recommendation based on the above evidence, and noted that while that the original VA rating decision did not rate radiculopathy, the 21 September 2007 VASRD changed the cervical spine rating description (above) to “spondylosis, cervical spine with headaches and right upper extremity radiculopathy and T-1 fracture.” The CI reported chronic (dominant) right shoulder pain as well as intermittent pain and paresthesias of both upper extremities, and was diagnosed with right radiculitis/suprascapular neuralgia. He was treated with suprascapular nerve blocks and epidural steroid injections, but continued to report right-sided neck pain and radiation down the posterior lateral right upper extremity. At the June 2005 VA C&P examination, he reported right shoulder pain with occasional paresthesias down the right arm to the fingers. He had difficulty raising his right arm and sometimes drop things due to pain. All examinations in record documented normal strength, sensation, and reflexes. The panel adjudged that a 20% rating, and no higher, was supported under 8710 for mild neuralgia of the upper radicular group (fifth and sixth cervicals). After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20%, coded 8710 for the cervical radiculopathy with neck spasm.

BOARD FINDINGS: In the matter of the “chronic pain syndrome, with neck spasm” condition, the panel recommends a disability rating of 30%, coded 5243 IAW VASRD §4.71a. In the matter of the Category II cervicogenic headache condition, the panel agrees it was unfitting and recommends a disability rating of 0%, coded 8199-8100 IAW VASRD §4.124a. In the matter of the Category II “cervical radiculopathy, with neck spasms” condition, the panel agrees it was unfitting and recommends a disability rating of 20%, coded 8710 IAW VASRD §4.124a. 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Pain Syndrome, With Neck Spasm	5243	30%	
Cervicogenic Headaches	8199-8100	0%	
Cervical Radiculopathy, With Neck Spasms	8710	20%	
	COMBINED	40%	

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 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 26 Dec 19
(b)	

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

2.	On 5 October 2020, the Assistant Secretary of the Navy took action in your case by accepting the correct recommendation of the PDBR.	Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Physical Evaluation Board from 10 to 40 percent with assignment to the Permanent Disability Retired List.

3.	The Assistant Secretary's determination, which represents final action in your case by the Department of the Navy, was sent to the Navy Personnel Command, for correction of your records as stated above.	You will be notified once those changes are complete.