RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-02299
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150317
SEPARATION DATE:  20050722

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Electrical and Environmental Systems Journeyman) medically separated for neck and back pain.  These conditions could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards.  She was issued a temporary U4L4 profile and referred for a Medical Evaluation Board (MEB).  The “chronic neck and back pain” were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB adjudicated her neck and back conditions as unfitting, rated 10% and 10% respectively, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Constant back pain with trouble lifting and climbing stairs.  Have had little to no relief since before I was released from duty.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

IPEB – Dated 20050607	VA* - (~13 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain…	5243	10%	Degenerative Disc Disease, Cervical Spine	5299-5242	10%	20060731	
Chronic Low Back Pain…	5243	10%	Degenerative Disc Disease, Lumbar Spine	5242	10%	20060731	
Other x 0 (Not In Scope)	Other x 7	
RATING:  20%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20070215 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Neck Pain Condition.  A magnetic resonance imaging (MRI) study of the cervical spine dated 9 December 2002 demonstrated diffuse disc bulging; most prominent at the 4-5 and 5-6 levels with focal bilateral protrusions at 6-7.  On 8 January 2003, the CI was evaluated by neurosurgery for right sided shoulder pain, localized to the trapezius region; right arm pain; and tingling in the fingers.  The examiner noted a history of occipital headaches 2-3 times per week and that the CI had under gone a course of physical therapy and oral corticosteroid without pain resolution.  A neurosurgery evaluation dated 3 February 2003 attributed the neck, shoulder, and right arm symptomatology to myofascial pain syndrome and the lumbar pain to discogenic pain from L5-S1.  The CI was referred to pain management for trigger point injections.  A military treatment visit dated 8 August 2003 noted continued neck pain, stiffness, and crepitus with a referral to pain management for post deployment resumption of care.  A pain management physical examination dated 13 August 2003 documented bilateral tightness at the upper back and shoulders (trapezius and scaphoid regions).  The examiner started a trial of Topamax for her chronic myofascial (neck and upper back) pain.  On 11 November 2003, the pain management provider recommended a series of cervical epidural injections for degenerative disc disease (DDD).  A treatment note dated 25 November 2003 noted a 60% improvement in her neck pain after her first steroid injection with a diagnosis of cervicalgia with cervical DDD.  At a pain management visit dated 11 February 2004 the CI reported worsening neck pain with daily headaches.  The physical examination was significant for pain with flexion of her neck and tenderness in the upper scapular regions.  The examiner injected her scapular trigger points and increased her anti-inflammatory medication for pain relief.  At pain management visit dated 10 May 2004 the CI reported increased neck and right upper back pain with headaches 1-2 times per week with resumption of her normal duties.  The examiner rendered a diagnosis of chronic cervicalgia with headaches.  The examiner opined that the CI had “a major component of a myofascial condition.”  Narcotic medication was added for severe exacerbations of her myofascial condition with recommendations for massage therapy and emphasis on the role of regular exercise in the management of myofascial pain.  On 6 July 2004, the CI underwent right scapula trigger point injections, was placed on 24 hours quarters, and activity restriction (2 weeks of no lifting over 10 pounds).  At subsequent pain management visits the CI received multiple trigger point injections and medication management without sustained relief of her neck pain.  A cervical MRI performed 6 April 2005 demonstrated subtle right disc protrusion or very small herniation at C 6-7 with some mass effect on the cervical cord.  The narrative summary (NARSUM) examiner noted that the CI was deemed not a surgical candidate, a neurosurgery diagnosis of myofascial pain syndrome, and a referral to pain management.  The physical examination documented full cervical range-of-motion (ROM) with pain in all directions.  The examiner documented that bilateral scapular trigger points on physical examination by pain management.  A diagnosis of chronic neck pain was rendered.

At the VA Compensation and Pension (C&P) examination performed 13 months after separation, the CI described constant, dull, aching neck pain.  She reported sharp pain three times per week lasting 5-10 minutes, but no incapacitating episodes.  The CI reported radiation of the neck pain to her upper back (trapezius).  The physical examination was significant for painful cervical motion all planes and discomfort in the trapezius with motion.  The examiner noted nontender shoulders.  Cervical ROM was documented as 35 degrees of flexion and extension, 25 degrees of lateral flexion bilaterally, and 60 degrees of rotation bilaterally.  A diagnosis of DDD of the cervical spine with radiation into both shoulders was rendered.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the chronic neck pain secondary to disc disease as unfitting.  The PEB and VA rated the cervical spine condition at 10%.  The PEB coded the chronic neck pain condition 5243 (intervertebral disc syndrome) and VA coded analogous to 5242 (degenerative arthritis of the spine).  The Board considered whether the evidence supported a higher than 10% rating for the chronic neck pain condition.  There was no evidence of cervical forward flexion restricted to 16-30 degrees, combined cervical ROM not greater than 170 degrees or, muscle spasm or guarding with abnormal spinal contour for a 20% rating under the VASRD general spine rating formula.  There was no evidence of incapacitating episodes for a rating under the VASRD intervertebral disc with incapacitating episodes rating formula.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 10% for the chronic neck pain secondary to disc disease condition was appropriately recommended in this case.

Back Pain Condition.  A pain management note documented that the CI was deployed to Iraq after one facet block injection and was resuming care after deployment.  A pain management treatment note dated 23 September 2003 documented intermittent relief of the low back pain (LBP) with facet joint steroid injections and anti-inflammatory medications.  An MRI study performed on 1 October 2003 revealed a small midline disc herniation at L5-S1 and mild lower lumbar degenerative facet disease.  A pain management treatment note dated 10 May 2004 documented a pain rating of 5-6/10 with return to work as an electrician.  The physical examination demonstrated that the CI was able to touch her toes, hyperextend her back, and had painful motion.  The examiner started narcotic medication for severe exacerbations of her back and neck pain.  At a pain management follow-up dated 3 September 2004 the examiner opined that the CI had “maxed out” her functional improvement and recommended that the CI retrain in order to continue her Air Force career.  Despite multiple medication trials, epidural steroid injections, and duty limitations, the low back pain condition persisted.  The NARSUM examination was significant for full extension, extension and rotation.  The examiner documented that bilateral lumbar trigger points on physical examination by pain management.  A diagnosis of chronic LBP was rendered.

At the VA C&P examination performed 13 months after separation, the CI described constant dull aching LBP.  She reported sharp pain three times per week lasting an hour.  She reported radiation of the back pain to her right leg.  The physical examination was significant for painful in all planes of thoracolumbar motion with normal posture and gait.  The thoracolumbar ROM was measured at 70 degrees of flexion (normal 90), 30 degrees of extension (normal), 25 degrees of lateral flexion bilaterally (normal 30), and 35 degrees of rotation bilaterally (normal 30).  The examiner noted that the observed painful motion was mild.  Diagnoses of DDD and degenerative joint disease of the lumbar spine were rendered.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the chronic LBP secondary to DDD as unfitting.  The PEB and VA rated the low back condition at 10%.  The PEB coded the chronic LBP condition 5243 (intervertebral disc syndrome) and VA coded the condition 5242 (degenerative arthritis of the spine).  The Board considered whether the evidence supported a higher than 10% rating for the chronic LBP condition.  There was no evidence of thoracolumbar forward flexion between 30 to 60 degrees, combined thoracolumbar motion not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour for a 20% disability rating.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 10% for the chronic LBP secondary to DDD condition was appropriately recommended in this case.

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 chronic neck pain secondary to disc disease condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic LBP secondary to DDD condition 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 re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131106, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXX

Dear XXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2013-02299.

	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 re-characterization or modification 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 re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR