RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX	CASE: PD-2017-06095
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20090730

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Food Service Specialist, medically separated for “thoracolumbar back pain” with a disability rating of 10%.

CI CONTENTION: Review the back condition with four “compressed vertebrae in mid to upper spinal cord.” 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 – 20090423	VARD – 20091123	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Thoracolumbar Back Pain	5237	10%	Degenerative Disc Disease Thoracolumbar Spine	5243	10%	20091007	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

Thoracolumbar Back Pain. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s back condition began in January 2002 after a fall. MRI studies in March 2008 showed multilevel moderate degenerative disc disease and endplate changes of mid thoracic spine. X-rays in March 2009 showed normal alignment of the lumbar spine without spondylolisthesis. There was no fracture, loss of vertebral body height or loss of disc height. Mild degenerative endplate changes were seen at L4 and L5.

During the 17 February 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported dull aching and sharp burning pain in the upper to mid back. Physical examination showed band like paraspinal tension and tenderness from T8 to T11. Straight leg raise testing was negative. The 6 March 2009 MEB NARSUM examination, 5 months prior to separation, noted complaints of daily agonizing pain. Physical examination showed a somewhat slow raise from a seated position, but the CI walked to the examination room without a noticeable limp. Range of motion (ROM) testing, after three repetitions, showed flexion of 75 degrees (normal 90) and combined ROM of 175 degrees (normal 240) with painful motion.  No muscle spasms were reported.

At the 7 October 2009 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported diffuse back pain, but the pain did not radiate into the arms or legs. The CI denied any prescribed bedrest. Physical examination showed a normal gait. There was tenderness in the lumbar paraspinals, but no spasms. Neurological evaluation was normal. The ROM study, after repetition, showed flexion of 90 degrees and combined ROM of 240 degrees with painful motion.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, coded 5237 (lumbar spine strain), citing forward flexion greater than 60 degrees but not greater than 85 degrees. The VA also rated the back condition 10%, coded 5243 (intervertebral disc syndrome (IVDS)), based on the C&P examination, citing painful motion of the spine with full ROM. Panel members agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the NARSUM examination. There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis. There was no documentation of IVDS with 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 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.

		PD-2017-06095

XXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXX

	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.

		PD-2017-06095

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