RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:	CASE:  PD1201977
BRANCH OF SERVICE:  ARMY	BOARD DATE: 20130717
SEPARATION DATE: 20060404

SUMMARY OF CASE:   Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (11C20/Indirect Fire Infantry) medically separated for chronic low back pain (LBP).  The CI’s back pain began after a motor vehicle accident (MVA) in Iraq in 2003.  Initially treated conservatively, he was later hospitalized for a month due to persistent pain.  X-rays were negative for additional lumbar injuries following a second MVA in 2004.  Physical therapy (PT) was continued along with various medications, but these yielded limited relief.  He re-deployed in early 2005 and upon return he was diagnosed with  disc bulges  and  degenerative disc disease  (DDD).  Medication and PT continuedand surgical intervention was ruled out.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent U2, L3 profile and referred for a Medical Evaluation Board (MEB).  The LBP condition, characterized as lumbago, spondylosis with L4-5, L5-S1 disc bulge and facet arthropathy was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-
501.  No other conditions were submitted by the MEB.  The PEB adjudicated chronic LBP as unfitting, rated 10%.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in his application.

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 rating for the unfitting “chronic low back pain secondary to degenerative disc disease with L4-5, L5-S1 disc bulge and facet arthropathy, without neurologic deficit, range of motion limited by pain, positive tenderness” condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  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 Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20060123	VA - (3 Mos. Pre-Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam

Chronic   LBP   Secondary   to
DDD w/L4-5, L5-S1 Disc Bulge
&   Facet   Arthropathy,   w/o
Neurologic	Deficit,	ROM
Limited    by    Pain,    Positive

5299-5242	10%

Lumbago Secondary to Spondylosis & DDD w/L4-5, L5-S1 Disc Bulge & Facet Arthropathy
Intermittent Loss of Urinary

5242-5243	10%*	20060131

Tenderness

Control a/w Back Condition	7599-7542	10%*	20060131

No Additional MEB/PEB Entries	Other x 6	20060131
Combined: 10%	Combined: 30%*
Derived from VA Rating Decision (VARD) dated 20060629 (most proximate to date of separation [DOS]).
* VARD dated 20070810 increased the back condition rating to 20% effective 20070313 and the urinary control condition to 40% also effective 20070313 (combined 70% with addition of PTSD).

ANALYSIS SUMMARY:

Chronic Low Back Pain.  The narrative summary notes that the CI had been referred to the MEB because of chronic, ongoing lower back pain with right inner thigh numbness, intermittent giving way of his right leg and loss of urinary control, following his injury in Iraq in March 2003. He was hospitalized in Iraq for about a month in May-June 2003 for evaluation, rest and treatment with PT.  Pain in the lower back and numbness and pain in the right inner thigh continued after his return to CONUS.  He also noted problems with urinary control, with loss of control occurring about once every 3 weeks on average.  He was involved in another MVA in October 2004, and X-rays and CT scans of the head and spine were negative following that accident.  The CI deployed again in January 2005 but was medevac’d to CONUS in June 2005 after sustaining injuries to his arm in an improvised explosive device (IED) blast.  At the MEB exam, the CI reported that he continued to experience LBP in spite of attempts at treatment with non-steroidal anti-inflammatory drugs, analgesics, opioids and muscle relaxers.  Discomfort radiated to the right hip and inner thigh and urinary difficulties persisted.  The MEB physical exam noted tenderness to palpation over the L3-S1 areas and mild spasm in the lower lumbar area.  Straight leg raising (SLR) was negative to 80 degrees.  Range-of-motion (ROM) is as recorded in the table below.  Lumbar spine X-ray series performed in August 2005 and repeated in October 2005 showed spina bifida occulta at the S1 level with normal vertebral alignment.  Vertebral bodies and disk spaces were intact.  No fracture, spondylolysis or spondylolistheses was seen.  Magnetic resonance imaging performed in November 2005 showed an L4-5 posterior disk bulge with facet arthropathy, and an L5-S1 disk bulge with facet arthropathy, causing foraminal stenosis at both levels.  Electromyogram (EMG) and nerve conduction studies (NCS) performed in November 2005 were normal bilaterally.  Neurosurgery consult on 28 November 2005 stated that there were no indications for surgical intervention regarding the CI’s DDD and bulging disks.  Urology consult on 19 December 2005 recommended only a trial of Detrol for bladder control.  The commander’s statement indicates that the CI’s back condition rendered him incapable of performing his duties as a Mortarman.

At the VA Compensation and Pension (C&P) exam performed 3 months prior to separation, the CI reported back stiffness, occasional weakness and inability to lift much without pain due to the spine condition.  He reported that he had suffered from pain located in his lower back for 3 years.  He denied having radiating pain on movement.  Examination of the thoracolumbar spine revealed tenderness with no muscle spasm.  SLR was normal bilaterally.  ROM measurements were as documented in the table below.  There were no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement, and neurological exam of the lower extremities was within normal limits.  A C&P exam 13 months post-separation documented greater limited forward flexion (60 degrees; normal 90 degrees) as charted below, with subsequent exam in 2009 indicating improved forward flexion to 80 degrees.

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM (Degrees)	PT ~6 Mo. Pre-Sep
(20051026)	MEB ~4 Mo. Pre-Sep
(20051220)	VA  C&P  ~3  Mo.  Pre- Sep
(20060131)	VA C&P ~13 Mo. Post-Sep
(20070511)	
Flexion (90 Normal)	60	75	80	60	
Extension (30)	20	25	20	20	
R Lat Flexion (30)	20	25	30	25	
L Lat Flexion (30)	25	25	30	30	
R Rotation (30)	Not measured	(20) 22	30	30	
L Rotation (30)	Not measured	(30) 28	30	30	
Combined (240)	UND	200	220	195	

Comment	Tenderness to palpation of paraspinals; mild spasm L1-L3 region	Discomfort limiting his movement & ROM. Mild spasm in lower lumbar area.   Heel & toe walk normal.	
Painful  motion. Posture  and  gait within normal limits.	Painful  motion.       No spasm   or   guarding. Motor and neurologic exams normal.	
§4.71a Rating	20%	10%	10%	20%	

The Board directs attention to its rating recommendation based on the above evidence.  The PEB characterized the back condition as “chronic low back pain secondary to degenerative disc disease with L4-L5, L5-S1 disc bulge and facet arthropathy, without neurologic deficit, range of motion limited by pain, positive tenderness.”  It coded it as analogous to 5242 (degenerative arthritis of the spine) and assigned a disability rating of 10%.  The VA characterized the condition as “Lumbago secondary to spondylosis and degenerative disc disease with L4-L5, L5- S1 disc bulge and facet arthropathy” and coded it 5242-5243 (intervertebral disk syndrome). Noting limitation of motion, it also rated the condition at 10%.  Subsequent VA exams over a year after separation were not considered indicative of the CI’s condition at the time of separation.  The Board considered that the MEB and C&P exams were both proximal to each other and relatively proximal to the date of separation.  Although there had been mention of right anterior leg numbness by the CI elsewhere in the record, sensory findings were not mentioned in the MEB exam and were said to be absent on the VA exam.  Neurosurgical consult performed on 28 November 2005, also describes normal sensation bilaterally and the examiner stated while there was “incontinence without urgency, there were no sphincter control problems.”  Furthermore, EMG and NCS were within normal limits.  The Board also considered coding under 5243 (intervertebral disk syndrome).  However, without evidence of incapacitating episodes during the 12 months prior to separation, members agreed that that coding option would not have led to a more favorable disability rating for the CI.  The Board concluded  that  given  the  degree  of  limitation  of  motion  due  to  pain  present in the examinations in evidence as well as the normal spinal contour and gait documented in the neurosurgery and C&P exams, the disability at the time of separation could not be rated higher than the 10% rating assigned by the PEB.  After due deliberation, considering all of the evidence and mindful of Veterans Affairs Schedule for Rating Disabilities (VASRD) §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the LBP condition.

The Board considered whether an additional rating could be recommended under a peripheral nerve or genitourinary system dysfunction code (neuropathy), as conferred by the VA, for the associated intermittent loss of urinary control associated with the back condition at separation. Firm Board precedence requires a functional impairment linked to fitness to support a recommendation for addition of a peripheral nerve rating or other residuals to disability in spine cases.  The sensory component in this case has no functional implications, no motor weakness was in evidence, and neurologic testing was normal.  The urinary control symptoms had been noted since March 2003 and did not interfere with deployment.   The increased

symptoms described in the VA records in March 2007 and thereafter were considered post- separation worsening and were not indicative of the condition at the time of separation.  There is thus no evidence of a separately ratable functional impairment (with fitness implications) from residual radiculopathy or urinary symptoms; and, the Board cannot support a recommendation for an additional disability rating on this basis.

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 LBP condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of any residual condition secondary to the back condition (peripheral nerve or urinary loss of control), the Board unanimously recommends no change in the PEB’s implied not unfitting 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	
Low Back Pain	5299-5242	10%	
	COMBINED	10%	

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20121212, w/atchs
Exhibit B. Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(TAPD-ZB)

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for AR20130019923 (PD201201977)

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						
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA