RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:	CASE:  PD-2017-0550	1
BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20051015
SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Rifleman, medically separated for “low back pain” with a disability rating of 20%.
CI CONTENTION: No specific contention was made. 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 - 20050829	VARD - 20060815	
Condition	Code	Rating	Condition	Code	Rating	Exam	
L5 Burst Fracture, Status Post L4-L5 Posterior Spinal Instrumentation and Fusion	5241	20%	Traumatic Fracture L5 With Surgical Fusion	5241	40%	20060724	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 60%	

ANALYSIS SUMMARY:

L5 Burst Fracture, Status Post L4-L5 Posterior Spinal Instrumentation and Fusion. According to the service treatment record and MEB narrative summary (NARSUM), after a motor vehicle accident the CI underwent lumbar spine fusion (L4-S1) and decompression of L5 and S1 nerve roots on 5 December 2004. The 27 June 2005 MEB NARSUM examination, 4 months prior to separation, noted complaints of low back pain associated with sitting, standing and any type of lifting despite surgery and physical therapy; the lower extremity paresthesia had resolved. Physical examination showed mild tenderness. Range of motion (ROM) was flexion to 60 degrees (normal 90) and combined ROM of 200 degrees (normal 240).

At the 18 November 2005 VA History and Physical examination, one month after separation, the CI reported low back pain rated 7-8/10. The examiner noted the CI was in no acute distress. Tenderness over the left paraspinous area of the lumbar region (site of bone harvesting) was noted, but there were no other abnormal findings. The assessment and plan were routine health

maintenance for chronic low back pain. X-rays of the lumbar spine were within normal limits status post fusion.

At the 24 July 2006 VA Compensation and Pension (C&P) examination, 9 months after separation, the CI reported low back pain and left lower extremity pain, weakness and numbness with flare- ups every 3-4 months. He was working as a tire bay mechanic. Physical examination showed a normal gait with mild to moderate spasms and tenderness; severe lumbar flattening was noted. The examiner noted muscle spasms, and localized tenderness or guarding was severe enough to be responsible for abnormal gait or spinal contour. ROM of the thoracolumbar spine was flexion of 20 degrees and combined ROM of 60 degrees with painful motion. The CI was unable to tolerate more than two repetitions.

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 40%, also coded 5241, based on the C&P examination, citing forward flexion of the thoracolumbar spine less than 30 degrees. The panel 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 NARSUM examination. There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula. At the post‐separation C&P examination the CI reported no interim history of further injury, surgery, or other aggravation of the condition. While ROM limitations may have progressed over time, there was no evidence in the record from which to conclude that the severity at separation approached that portrayed by the VA measurements. 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 back condition.

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

The following documentary evidence was considered:

2	PD-2017-05501

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

IN REPLY REFE R 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.