RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	 CASE:  PD-2014-01694	
BRANCH OF SERVICE:  Army	 BOARD DATE:  20150512
SEPARATION DATE:  20090729		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Medium Truck Driver) medically separated for neck and back conditions.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent U3L3 profile and referred for a Medical Evaluation Board (MEB).  The neck and back conditions, characterized as “chronic cervicalgia with C4-5 and C5-6 degenerative disc disease” and “chronic low back pain with L4-5 degenerative disc disease,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded 10 other conditions.  The Informal PEB adjudicated “cervical degenerative arthritis” and “lumbar degenerative disc disease with MRI [magnetic resonance imaging] findings at L4-5,” as unfitting, rated 10% and 10%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  “Difficulty maintaining desired civilian employment based on disabilities.  Would have remained in the service if not for these conditions.”  

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:  

Service IPEB – Dated 20090701	VA - (2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Degenerative Arthritis	5242	10%	Degenerative Disc Disease, C4-5 and C5-6	5243	10%	Not available	
Lumbar Degenerative Disc Disease With MRI Findings At L4-5	5242	10%	Degenerative Disc Disease, L4-5	5243	10%	Not available	
Other x 10  (Not in Scope)	Other x 5 (Not in Scope) 	Not available	
Combined:  20%	Combined:  70%	
Derived from VA Rating Decision (VARD) dated 20091105 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Cervical Degenerative Arthritis.  At a chiropractic visit dated 25 June 2008, the CI reported pain in the entire back that worsened with exercise.  She denied radicular symptoms; specifically pain, weakness, and numbness of the lower extremities.  The lumbosacral spine examination demonstrated painful, but full, range-of-motion (ROM) motion and normal curvature.  The neuromuscular examination was normal to include a normal gait and negative straight leg raise (SLR).  Radiographs dated 25 June 2008 documented loss of the normal lordosis of the cervical spine, normal alignment of the spinous processes, and preserved disc space and vertebral body height.  A cervical MRI dated 24 July 2008 documented decreased cervical lordosis, C4-C5 and C5-C6 posterior disc bulge with bilateral neural foraminal narrowing (moderate on the left; mild on the right).  At a physical medicine appointment dated 10 July 2008, the CI reported a 3-year history of neck pain currently 3-4/10, poor sleep, and no significant relief with chiropractic treatments, physical therapy, and electrical stimulation.  She denied upper extremity radicular symptoms.  The examiner documented tenderness to palpation of the bilateral cervical paraspinal musculature, extending to the upper back bilaterally, with no weakness or painful motion noted.  The examiner diagnosed “myofascial pain” which was treated with “trigger point injections.”  At a neurosurgical consultation dated 29 August 2008, the CI reported back pain unrelieved by multiple modalities, “numbness and tingling in different parts of her body, but nothing presently,” and inability to get out of bed when the pain is the most severe.  The examiner documented normal coordination, strength, and sensation of the upper extremities. The examiner opined that surgical intervention was not required.  He recommended continuation of physical therapy and referral to the pain clinic.  At a visit dated 16 October 2008, the CI reported worsening neck during early morning rising with minimal improvement on medications.  The examiner documented bilateral neck and upper back tenderness to palpation, painful motion, and full ROM without instability.  

At the MEB examination dated 5 January 2009, the CI reported worsening neck issues resulting in inability to “get up some morning… sitting and standing too long is extremely painful,” and reported occasional numbness and tingling in her arms and hands.  The MEB physical examiner documented tenderness to palpation of the cervical spinous, painful motion, and normal sensation, strength and symmetric reflexes.  There was pain in the cervical spine with axial loading and negative Spurling’s test (for radicular pain).  The initial narrative summary (NARSUM) dated 13 January 2009, the examiner noted that intervertebral disc disease was not responsive to multiple modalities and that there were no surgical options.  The pain was reported as a sharp stabbing pain with intermittent numbness and tingling in the bilateral upper extremities.  She rated the pain 6/10 at baseline which flared to 9-10/10 approximately twice per month; lasting hours and resulting in decreased ROM in all planes of movement.  The examiner documented painful cervical motion.  Sensation, strength, and reflexes were normal and symmetric.  Provocative testing did not elicit radiculopathy.  No upper extremity atrophy was noted.  At visit dated 26 January 2009, the examiner stated that the CI had “C5-C6 disc bulge with foraminal encroachment, left much greater than on the right, with concordant bilateral C5 dermatome pain.”  The examiner stated that the CI was doing well with Gabapentin (for nerve pain) and Celebrex (nonsteroidal anti-inflammatory).  In a NARSUM addendum dated 1 June 2009, the examiner documented pain limited ROM for the cervical, no spasm or abnormal curvature; and normal sensation, coordination, strength and reflexes of the upper extremities.  

The VARD dated 5 November 2009 referenced several examinations in September 2009.  The neck pain was stated to be not as severe as the low back pain, was rarely incapacitating, and flared once to three times per month.  The cervical ROM was recorded as normal without pain, decrements after repetition, or findings of nerve root impingement.  The radiographs reviewed documented no significant changes in the cervical suggestive of degenerative disease.  The VA examiner diagnosed chronic myofascial pain involving the cervical due to chronic strain.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the cervical degenerative arthritis condition as unfitting and rated 10% coded as 5242 (degenerative arthritis of the spine) for tenderness and limitation of motion.  The VA rated the neck condition at 10% coded as 5243 (intervertebral disc syndrome) for episodes of incapacitation.  The Board considered whether the evidence supported a higher than 10% rating for the neck condition.  The service treatment record (STR) documented evidence of painful motion, limitation of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees, muscle spasm with radiographic evidence of abnormal cervical spine contour (decreased lordosis), and C4-C5 and C5-C6 posterior disc bulge.  There is no documentation of cervical ankylosis, flexion less than 30 degrees, or combined ROM less than 170 degrees to warrant a higher rating.  There was no evidence of a radiculopathy that rose to the level of separately unfitting for additional disability 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 neck condition.  

Lumbar Degenerative Disc Disease.  At the chiropractic visit dated 25 June 2008, the CI reported pain in the entire back.  She denied radicular pain, weakness, and numbness of the lower extremities.  The lumbosacral spine examination demonstrated painful, but full ROM motion, normal curvature.  The neuromuscular examination was normal.  Lumbosacral spine radiographs dated 25 June 2008 documented scoliosis without significant osteoarthritic changes, fractures or dislocations.  A Scoliosis survey, dated 3 July 2008, documented 8 degrees of levoscoliosis (left curved scoliosis) of the lumbar spine.  An MRI dated 24 July 2008 documented L4-L5 posterior disc bulge and tear with mild left neural foraminal narrowing.  At a physical medicine appointment dated 10 July 2008, the CI reported 3-4/10 back pain despite multiple treatment modalities.  She denied lower extremity radicular pain and weakness.  She denied bowel or bladder problems.  The examiner documented that the gait and lumbosacral spine appeared normal.  There was tenderness to palpation of the bilateral lumbosacral paraspinous musculature with muscle spasms.  The neurologic examination was normal and without evidence of radiculopathy.  The examiner rendered a diagnosis of myofascial pain.  At a neurosurgical consultation dated 29 August 2008, the examiner documented normal gait with normal coordination, strength, and sensation of the lower extremities with a negative SLR.  The examiner opined that the CI was not a surgical candidate.  At a visit dated 16 October 2008, the CI reported worsening low back pain in the morning, decreased ROM, and numbness and tingling in the lower extremities.  The examiner documented a normal gait, full ROM, normal curvature of the lumbar spine, and painful motion on right lateral flexion.  The neurologic examination was normal.  

The MEB (5 January 2009) examiner documented tenderness to palpation of the thoracolumbar spinous processes and bilateral paravertebral musculature, and painful motion.  The neurologic, lower extremity strength, and gait examinations were normal.  The NARSUM examination, dated 13 January 2009, documented painful motion throughout the thoracolumbar examination with forward flexion of 82 degrees after repetition (normal is 90 degrees) and a functional combined thoracolumbar ROM of 204 degrees (normal is 240 degrees).  Sensation, strength, and reflexes were normal and symmetric.  Provocative testing did not elicit radiculopathy.  No upper or lower extremity atrophy was noted.  Gait was normal.  An L4 and L5 epidural steroid injection was performed on 19 February 2009.  At a clinic visit dated 12 March 200, the CI requested more medications.  The thoracolumbar spine examination documented no muscular spasms, negative SLR, normal ROM, sensation, reflexes and strength.  In a NARSUM addendum dated 1 June 2009, the examiner documented pain limited thoracolumbar ROM without spasm or abnormal curvature of thoracolumbar spine; slight difficulty lowering to and rising from a seated position and a non-antalgic gait.  The SLR was negative.  

The VARD dated 5 November 2009 referenced several incapacitating events requiring emergency room visits for injections.  The thoracolumbar spine ROM was recorded as normal without painful motion, decrements after repetition, and findings of lower extremity radiculopathy.  The VA examiner diagnosed chronic myofascial pain involving the lumbar spine due to chronic strain.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the lumbar degenerative disc condition as unfitting and rated 10%; coded 5242 (degenerative arthritis of the spine) for tenderness and limitation of motion.  The VA rated the low back condition at 10% for episodes of incapacitation; coded 5243 (intervertebral disc syndrome).  The Board considered whether the evidence supported a higher than 10% rating for the back condition.  The STR documented evidence of painful motion, limitation of motion, and radiographic evidence of L4-L5 disc degeneration.  There was no documentation of thoracolumbar ankylosis, flexion less than 60 degrees, or combined ROM less than 120 degrees to warrant a higher rating.  There was no evidence of a radiculopathy that rose to the level of separately unfitting for additional disability rating.  The Board also considered rating the low back pain condition under the general rating formula for intervertebral disc disease, but determined that the one episode of incapacitation would not result in a 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 low back 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 degenerative arthritis and lumbar degenerative disc disease 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 re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140409, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXX, AR20150013457 (PD201401694)

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						     XXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA