RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXX CASE: PD1201954 BRANCH OF SERVICE: ARMY BOARD DATE: 20130314 SEPARATION DATE: 20031215 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (97E/Intelligence-Trainee) medically separated for cervical and lumbar spine conditions (C-spine and L-spine conditions). She experienced an atraumatic onset of radiating neck pain and low back pain (LBP) in 2002. She was diagnosed with cervical and lumbar disc disease; and, surgical options were ultimately deferred. She did not respond adequately to conservative measures for either spine condition to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent U4/L3 profile and referred for a Medical Evaluation Board (MEB). The cervical and lumbar spine conditions, characterized as “cervical herniated nucleus pulposus” (HNP) and “chronic low back pain,” were forwarded to the Physical Evaluation Board (PEB) as failing to meet retention standards IAW AR 40-501. The PEB adjudicated both spine conditions as unfitting, rated 10% each, with likely application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals, and was medically separated with a 20% combined disability rating. CI CONTENTION: “Physical Therapy is outsourced from VA hospital and only allowed certain # of visits for therapy; example – 12 which is not sufficient. A long process is typical to take place IOT see the physician (primary) then get referral to Physical Therapy, then an Orthopedic physician examines me to determine if I need physical therapy treatments. These treatments have been pre-determined sessions since Hurricane Katrina and I then have out of pocket expense to exceed disability amount.” SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The ratings for the unfitting lumbar spine and cervical spine conditions are addressed below. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the respective Army Board for Correction of Military Records. The Board takes note of the CI’s assertions regarding her post-separation medical treatment; but, must clarify that its jurisdiction resides solely with the assessment of the fairness of disability ratings. Redress for the specific contentions elaborated in the application must be sought from the Department of Veterans Affairs (DAV) and/or through judiciary channels. RATING COMPARISON: Service IPEB – Dated 20030930 VA - (2 Mos. Post-Separation) Condition Code Rating Condition Code Rating Exam HNP, C6/C7 5243 10% HNP, C6/C7 5237 10% 20040209 Chronic Low Back Pain 5237 10% Lumbar Disc Disease at L3-L4 5242 10% 20040209 No Additional MEB/PEB Entries Other x 2 20040918 Combined: 20% Combined: 20% ANALYSIS SUMMARY: Cervical and Lumbar Spine Condition: The CI had an insidious onset of neck and LBP with radiation to the left arm and left hip, respectively. She had a motor vehicle accident prior to entry into service with no history or reported trauma since then. She sought care in November 2002 with severe neck and low back pain with an intensity of anywhere from a 5-10 of 10 which increased while sitting in class. Multiple conservative modalities to include: physical therapy, nonsteroidal anti-inflammatory medications (NSAIDs), and muscle relaxers provided minimum relief. She underwent two separate neurosurgery evaluations whose exams corroborated the magnetic resonance imaging (MRI) findings of disc disease HNP at the C5-6 and C6-7 levels with radiculopathy and degenerative disc disease (DDD) at L3-4 level without radiculopathy. The neurosurgeon offered more invasive treatment modalities to include, pain management, trigger point injections, epidural injections for the lumbar spine and finally surgery for the C-spine. She opted for the more aggressive nonsurgical approaches and subsequently was referred for a MEB 6 months after her initial evaluation. The permanent profile limitations included no running, jumping or marching, no sit-ups or push-ups, no physical fitness testing and unable to carry a rucksack. She was only allowed to lift 20 pounds and walk, bicycle and swim at her own pace and distance. At the MEB exam, the CI reported pain at the base of the neck and between the shoulder blades, at the lower back and tailbone with radiation as noted above with associated headaches and sleep disturbances. The pain worsened with prolonged sitting and prolonged standing and was relieved with stretching, heat, traction, and sometimes physical activity. She reported taking the muscle relaxant Skelaxin. She additionally reported the following limitations: able to run 10 minutes on a treadmill, write for 15 minutes, sit in a vehicle for up to 40 minutes and stand for 10-15 minutes. The MEB physical exam of the C-spine demonstrated full active range- of-motion (ROM) with pain on rotation and extension, negative Spurling’s test (provocative test for disc disease), 5/5 strength in all extremities however there was slight weakness of the left biceps compared to the right and no pathologic reflexes. The plain X-rays of the C-spine revealed slight loss of cervical lordosis and the MRI revealed HNP at C5-6 and C6-7. The exam of the L-spine revealed full lumbar ROM, tenderness to palpation of paraspinal muscles on the left and negative straight leg raising (SLR) bilaterally (provocative sign for disc disease). Plain X- rays of the L-spine were negative. MRI revealed mild DDD at L3-4 with no focal disc herniation. The examiner diagnosed severe cervical thoracic pain with radiation and numbness and to left upper extremity, slight left upper extremity weakness of biceps muscle, cervical disc disease at C5-6 and C6-7 with C6-7 herniated nucleus pulposus and lumbar disc disease at L3-4 with chronic low back pain. At the VA Compensation and Pension (C&P) exam performed 2 months after separation, the CI reported getting physical therapy since 2002, and the symptoms were much improved since she started. She reported at one time she had numbness and pain in her upper extremities, but this was totally resolved and she was currently taking the muscle relaxants, Skelaxin, and Tizanidine. The C&P exam demonstrated normal posture and gait, no muscle spasm, mild pain on auscultating over her low neck and lower back, full painful range of motion of the neck and full ROM of the low back, negative SLR and otherwise normal neurologic findings. A neurologic specialty exam demonstrated painful neck flexion, the left handgrip slightly weaker but this may be due to her right handedness. The lower extremities revealed normal neuromuscular findings, normal gait and stance and able to walk on her heels and toes. X-rays of L-spine were normal. The Board directs attention to its rating recommendation based on the above evidence. The PEB and VA chose different coding options for the C-spine condition which did not bear on rating; but the Board agreed that the code chosen by the MEB, 5243 (Intervertebral disc syndrome), is more representative of the clinical pathology related to the CI’s condition. The PEB and the VA achieve the same 10% rating applying the general rating formula for diseases and injuries of the spine for the painful motion with flexion IAW VASRD the §4.71a 5243 code or with VASRD §4.59 (painful motion). There is no evidence of spasm, guarding, abnormal gait, abnormal spinal contour, ankylosis, or incapacitating episodes to justify a higher rating than 10%. The Board considered the VASRD formula for rating intervertebral disc syndrome based on incapacitating episodes and invoked the VASRD definition for incapacitating episodes which requires “bed rest prescribed by a physician and treatment by a physician.” There is no such evidence to support a higher rating under this formula. The Board considered additional rating for peripheral nerve involvement and notes neither the PEB nor the VA rated the objective left bicep weakness IAW §4.124a Schedule of ratings–neurological conditions and convulsive disorders. Board precedent is that a functional impairment tied to fitness is required to support a recommendation for addition of a peripheral nerve rating at separation. The radicular component in evidence in this case consisted primarily of pain, which is subsumed under the general spine rating formula. There is no objective evidence for functional impairment related to the left bicep motor deficit. Therefore, there is no evidence of ratable peripheral nerve impairment to justify additional rating. The Board, therefore, does not find reasonable doubt favoring a recommendation for additional rating. The Board finally considered the rating recommendation for the L-spine condition. The PEB and VA chose different coding options which did not bear on rating and both applied the general rating formula for diseases and injuries of the spine. The PEB achieved a 10% rating despite the lack of evidence for painful motion or limitation of motion; however the Board's recommendation may not produce a lower rating than that of the PEB. The VA achieved the same 10% for the painful motion of L- spine IAW VASRD §4.71a 5242 code (degenerative arthritis of the spine) or with VASRD §4.59. There is no evidence of documentation of incapacitating episodes or ratable peripheral nerve impairment which would provide for additional or higher rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the cervical and lumbar spine condition. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the cervical and lumbar spine conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING HNP, C6/C7 5243 10% Chronic Low Back Pain 5237 10% COMBINED 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20121202, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record XXXXXXXXXXXXXXXXXXX, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / XXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXX, AR20130006070 (PD201201954) I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl XXXXXXXXXXXXXXXXXX Deputy Assistant Secretary (Army Review Boards)