RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2021-00116
BRANCH OF SERVICE:  Air force 	SEPARATION DATE:  20071214

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Air Command and Control Journeyman, medically separated for “low back pain due to herniated nucleus pulposus with sciatica” with a disability rating of 10%.   

CI CONTENTION:  Given a higher rating by the VA for the back condition.  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 - 20071011	VARD - 20080710	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain…	5243	10%	Lumbosacral Trauma with Residuals Stenosis of L4-L5 with Disc Protrusion at L4-L5 and L3-L4	5237	10%	20080123	
			Radiculopathy, Right Lower Extremity  Associated with Lumbosacral Trauma with Residuals Stenosis of L4-L5 with Disc Protrusion at L4-L5 and L3-L4	8520	10%	20080429	
			Radiculopathy, Left Lower Extremity Associated with Lumbosacral Trauma… 	8520	10%	20080429	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50% 	

ANALYSIS SUMMARY:  

Low Back Pain (LBP).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in August 2006 after a period of increased physical training.  At a neurosurgery visit on 11 September 2006, the CI reported LBP and lateral left lower extremity (LLE) numbness, but physical findings were unremarkable.  A lumbar spine MRI showed significant degenerative disc disease and a herniated disc to the right at L5-S1.  The neurosurgeon stated that surgery was unlikely to be of benefit since there were no clinical findings of right lower extremity (RLE) radiculopathy and the CI’s main symptom was back pain.  An EMG on 12 October 2006 showed bilateral L5-S1 radiculopathy.  A 7 November 2006 neurosurgery second opinion noted LBP complaints with radiation to both LEs, without bowel or bladder problems.  Physical examination was unremarkable with normal LE strength, sensation, reflexes, and gait; the specialist recommended starting with non-operative treatment.  A thoracic spine MRI on 1 February 2007 showed minimal disc bulges at T9-10 and T12.  

During a physical therapy (PT) appointment on 8 March 2007, range of motion (ROM) tests were normal in all planes but with endpoint pain.  The examiner noted tenderness and muscle spasm and guarding without abnormal gait or spinal contour.  

At the 24 April 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported arthritis, numbness, and tingling (second page of the history was missing).  The examiner documented mild midline tenderness at L5-S1.  

From March-May 2007, chiropractic treatment initially relieved the CI’s muscle spasms and LE pain, but symptoms eventually returned.  At a PT visit on 16 May 2007, he reported increased LBP and the examiner noted lumbar and paravertebral muscle tenderness.  Straight leg raise (SLR) testing to elicit radicular symptoms was negative and back ROM measurements were normal, with RLE radiation pain.  Home exercises were prescribed before the next appointment.  

During a neurosurgical consult on 6 June 2007, 6 months before separation, the CI reported chronic LBP and mostly RLE pain, with recent LLE symptoms as well.  Physical findings showed a normal gait and paraspinal muscle tenderness.  Bilateral LE strength and reflexes were normal and SLR tests were negative, but decreased LLE sensation was noted in the S1 distribution compared to the right.  An MRI in February 2007 showed a bulging disc with annular tears at L4-5, facet arthropathy, and a herniated disc at L5-S1 displacing the right S1 nerve root.  Surgical benefit was unclear since the MRI findings were on the right, but the CI’s symptoms were on the left.  The examiner recommended a trial of epidural steroid and possible facet joint injections.  

The 2 August 2007 MEB NARSUM examination, 4 months prior to separation, documented CI complaints of continued LBP, and that the physical examination was “not significant.”  The 23 August 2007 MEB PT examination recorded thoracolumbar flexion to 90 degrees (normal) and a combined ROM of 235 degrees (normal 240).  The examiner noted tenderness, but no muscle spasm or guarding, and no abnormal gait or spinal contour.  

At a VA physical medicine and rehabilitation (PMR) examination on 4 January 2008, 1 month after separation, the CI reported LBP that radiated to both buttocks and posterior thighs, with intermittent numbness in both feet, but no bowel or bladder dysfunction.  Physical findings revealed normal LE strength, sensation, and reflexes.  Repeat EMG studies showed evidence of a bilateral lower lumbar radiculopathy.  At another PMR visit 10 days later, the provider noted a normal gait, no back tenderness, and normal LE strength and reflexes.  Lumbosacral ROM was full in all planes, with painful motion noted on right lateral bending.  The examiner recorded decreased sensation to light touch and pinprick in the RLE in multiple lumbar dermatomes.  

The 23 January 2008 VA Compensation and Pension (C&P) orthopedic examination noted CI complaints of LBP radiating to the right thigh and numbness in the right leg at times.  He endorsed flare-ups 2-3 times a week after heavy lifting or exercise, with pain rated at 8/10, and a 50% decrease in ROM; the pain was alleviated by rest.  The examiner noted spasm and tenderness in the L4-5 area.  Thoracolumbar ROM was normal other than 20 degrees of extension (normal 30).  After four repetitions, pain increased to 5-6/10 with a mild increase in fatigue, but no weakness or change in ROM.  Reflexes were 2+ in the knees and right ankle, and 1+ in the left ankle.  Sensation was decreased in the L3-4 root nerve root distribution on the left.  
At the 17 March 2008 VA PMR visit, 3 months after separation, the CI reported LBP, left greater than right, with some numbness and aching down the back of the legs and numbness in both big toes.  He felt his legs were weaker and had caused recent tripping.  Physical findings revealed a normal gait and paraspinal and sacral tenderness.  Measured lumbosacral ROM showed full flexion without pain, extension at “75% of full” with pain, and full side bending with pain greater on the right.  The examiner documented normal reflexes and mildly decreased sensation in the right medial foot and ankle.  Strength was normal in both LEs, except for a mild decrease in the right hip flexor (L2) myotome.  Seated and supine SLR tests were negative bilaterally and X-rays showed mild degenerative spondylosis at L5-S1.  

An MRI on 14 April 2008 showed mild multilevel degenerative spondylosis that affected the L5-S1 level most, with “very mild compressive effects on the thecal sac and right-sided S1 nerve root.”  At a PMR follow-up the next day, the CI reported LBP with radiation to the right buttock, paresthesias of the right foot, and persistent problems with LE exertional fatigue.  On examination, the provider noted ROM and reflexes unchanged from the previous examination.  Strength was graded 5/5 throughout both LEs, and while the CI was able to heel and toe walk and had symmetrical toe raises, he reported fatigue on the right.  Sensation was decreased throughout the RLE dermatomes from L3-S1, and worst at S1.  The CI was referred to neurosurgery for surgical consideration.  

At the 29 April 2008 VA C&P neurological examination, 5 months after separation, the examiner was asked to evaluate LBP and bilateral lumbar radiculopathy with a history of decreased left foot sensation.  The CI rated his LBP at 5-7/10 and endorsed associated spasm and pain radiating to both LEs at times; he also reported numbness in both feet.  The examiner referenced a recent EMG, which showed bilateral lumbar radiculopathy.  Physical examination showed a normal gait (including heel and toe walk), no muscle spasm, and L4-L5 paravertebral muscle tenderness.  Flexion was to 75 degrees (with pain beyond this measurement), extension to 18 degrees, and lateral rotation and flexion to 20 degrees.  Mildly decreased sensation was noted in the L5 distribution of the feet, with “no major sensory loss detected.” Straight leg raise testing noted “up to 65 degrees” with no further comment.  

A neurology consult on 8 May 2008 showed a normal gait and LE strength, except for hip flexion limited by pain bilaterally, graded 4/5.  Sensory testing was non-focal, reflexes were normal, and SLR tests were positive bilaterally.  The provider assessed that the LBP and weakness were likely due to radiculopathy, and that physical findings correlated “well to the MRI findings of L5-S1 disease and bilateral S1 impingement.”  The weakness was thought to be related to pain because the CI had weakness “unrelated to the areas of spinal cord involvement.”  The examiner prescribed Neurontin with a repeat MRI in 3 months if the pain did not improve.  Notes in the VA record in December 2008, 12 months after separation, indicated the CI was employed by the Army as a civilian and was going to deploy to Afghanistan for 6 months in January 2009.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5243 (intervertebral disc syndrome).  The VA also rated the back condition 10%, but coded 5237 (lumbosacral strain), based on the C&P examination and citing thoracolumbar flexion greater than 60 degrees but not greater than 85 degrees; or, combined thoracolumbar ROM greater than 120 degrees but not greater than 235 degrees.  Panel members agreed that a 10% rating, but no higher, was justified for limitation of flexion or tenderness/painful motion as reported on examinations proximate to separation.  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.  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 LBP.  

CONTENDED PEB Condition:  Radiculopathy.  Panel members noted that the PEB rated “low back pain due to herniated nucleus pulposus with sciatica” and rendered a de facto not unfitting determination for the sciatica by not rating it separately.  Sciatica refers to pain radiating along the sciatic nerve but is often used interchangeably for radiculopathy.  Thus, the panel agreed sciatica was in the scope of review and should be addressed.  The presence of functional impairment with a direct impact on fitness is the key determinant in a decision to recommend rating any condition as additionally unfitting.  The VASRD general spine rating formula includes diseases and injuries of the spine “with or without symptoms such as pain (whether or not it radiates).”  So, although the CI was diagnosed with bilateral lumbar radiculopathy by EMG, the critical decision is whether there was significant muscle weakness or sensory deficit which would impact specific military occupational activities.  Panel members noted that essentially all examinations in the record showed normal LE strength and reflexes.  While one neurosurgical consult noted decreased LLE sensation, subsequent examinations before separation did not confirm this assessment.  After separation, serial examinations documented sensation as follows (in the stated areas only and normal otherwise): fully normal; questionable decrease in the RLE in multiple dermatomes; decreased in the L3-L4 nerve root areas; decreased in the right medial foot and ankle; decreased on the right from L3-S1; mild decreased sensation in the L5 distribution of both feet; and finally, from the May 2008 neurosurgery consult, a non-focal sensory examination.  The panel concluded there was no objective evidence of a stable functional impairment related to the L5-S1 radiculopathy noted on EMG, or that the intermittent and variable sensory findings had any impact on fitness.  The panel therefore concluded that an additional disability rating was not justified on this basis.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the low back pain due to herniated nucleus pulposus with sciatica and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended radiculopathy, 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.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20211216, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

SAF/MRB
3351 CELMERS LANE
JBA NAF WASHINGTON, MD 20762-6435

Dear XXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2021-00116.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no rating modification or re-characterization of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that modification of your disability rating or characterization of your separation is not warranted.  Accordingly, I accept the recommendation that your application be denied.

						Sincerely,