RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: BRANCH OF SERVICE: AIR FORCE

CASE NUMBER: PD0900459 BOARD DATE: 20100127

SEPARATION DATE: 20080725

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SUMMARY OF CASE: This covered individual (CI) was a Staff Sergeant/E5 (Aerospace Medical Service Craftsman) medically separated from the Air Force in 2008 after 11 years of service. The medical basis for the separation was Neck Pain, Status Post C5-6 Anterior Cervical Diskectomy and Fusion. The CI developed neck pain after a motor vehicle accident and her symptoms persisted after extensive therapy including surgery. She was referred to the Physical Evaluation Board (PEB), found unfit for continued military service, and separated at 20% disability using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Air Force and Department of Defense regulations.

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CI CONTENTION: “At the time of my evaluation I was informed that pain could not be rated. I suffered daily with left side neck / left arm pain where at times I can hold my head up. I am currently taking lyrica 50 mg. x 3 a day with neurontin 600 mg. I never know if my left arm is (continued) going to give out, I have trouble grabbing or holding things in my left hand. I suffer with severe pain from my neck that triggers vertigo with episodes of vomiting, nausea, trouble walking or standing for several day.

Since the surgery I suffer from constant ringing in left ear.”

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RATING COMPARISON:

Service PEB	VA (3+ to 9 MOS after Separation)
Unfitting Conditions	Code	Rating	Date	Condition	Code	Rating	Exam	Effective
Neck Pain, Status Post C5-6 Anterior Cervical Diskectomy and Fusion	5242	20%	20051012	Cervical Spine, S/P C5-6 Anterior Discectomy and Fusion w/Degenerative Arthritis and Degenerative Disc Disease	5242- 5243	20%	20081115,	20080726
Additional Conditions (list all PEB conditions)	PEB	DES (If Yes, List Where: NARSUM, H&P, Etc)	Code	Rating	Exam	Effective
	No	NARSUM	Left Upper Extremity, Cervical Radiculopathy and Cervicalgia	8599- 8515	10%	20081115,	20080726
	No	NARSUM TAH, ovaries intact	S/P Hysterectomy	7618	30%	20081115,	20080726
	No	NARSUM Cholecystectomy	Gastroesophageal Reflux, Status Post Nissen Fundoplication w/Hiatal Hernia Repair, History of Gastritis, and S/P Cholecystectomy	7399- 7346	30%	20081115, 20090609	20080726
	No	NARSUM	Lumbosacral Spine, Degenerative Joint and Disc Disease (Claimed as Backache)	5243- 5242	0%	20081115,	20080726
	No	Not in DES paperwork	Tinnitus	6260	10%	20081118, 20090107	20080726
	No	Not in DES paperwork	Left Ear Hearing Loss	6100	0%	20081118, 20090107	20080726
	No	Not in DES paperwork	Benign Paroxysmal Postural Vertigo	6299- 6204	0%	20090107	20080726
	No	Not in DES paperwork	S/P Left Ovarian Cyst	7615	0%	20081115,	20080726
	No	C/S in NARSUM, not scar	Postoperative Scar, Anterior Cervical Spine	7800	0%	20081115,	20080726
	No	TAH in NARSUM, not scar	Scar, Lower Abdomen, S/P Hysterectomy	7802	0%	20081115, 20090609	20080726
No Additional PEB Entries	Non-PEB X 10 / NSC 7
TOTAL Combined: 20%	TOTAL Combined (Includes Non-PEB Conditions): 70% from 20080726

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ANALYSIS SUMMARY:

Condition 1: Neck Pain, Status Post C5-6 Anterior Cervical Diskectomy and Fusion 5242

The CI had a C5-6 anterior cervical diskectomy and fusion on 27 Jun 06. She was in a motor vehicle accident in December 2003 and had left posterior neck pain that radiated along her posterior mid-trapezius on the left and down the left arm all the way to the fingertips. This pain continued to worsen over time. She deployed to UAE for over four months as a medical technician and was quite busy lifting gurneys/litters as part of her daily routine there. She was seen for worsening left arm pain a couple of times while in the UAE. She was treated with Midrin and morphine there, but was able to continue her duties while deployed. She returned to McGuire in September 2004 and was still having worsening pain so she sought care at the clinic again and was referred for an MRI and pain management consult. A comprehensive diagnostic work-up was completed and she also had referrals to neurology, orthopedics, and neurosurgery. Neurology injected trigger points but this did not relieve her pain. The neurosurgeon recommended diskectomy and fusion and this was done in June 2006. An MRI done prior to the surgery (18 Nov 05) showed a 0.1 cm retrolisthesis at C5-6. There was also a moderate bulging disc as well as moderate posterior osteophytes. There was associated mild spinal stenosis. At C4-5, there was a mild bulging disc as well as mild posterior osteophytes. A previous MRI was also abnormal. A 4 May 04 MRI documented multilevel degenerative disc disease within the cervical spine. The findings were most pronounced at C5-6. There was a moderate spondylitic disc bulge, creating moderate central canal stenosis, with abutting and/or mild impression on the ventral cervical cord. An EMG done in June 2004 was normal. After the surgery she gradually improved but still had persistent recurrent flare-ups of severe spasm and pain of the left upper back, left posterior neck that radiated to her left occiput and down her left arm. An EMG done after the surgery in August 2007 did not demonstrate any evidence of acute or chronic left cervical radiculopathy or plexopathy. However, intense spasm was noted in the cervical paraspinals and left trapezii. Borderline left cubital tunnel syndrome was present and there was no evidence of left carpal tunnel syndrome.

The Air Force PEB determined this condition was unfitting for continued military service. While the Air Force examination does not include range of motion (ROM) measurements, the VA examination includes a complete ROM examination. IAW VASRD §4.71a and the General Rating Formula for Diseases and Injuries of the Spine, the rating for this unfitting condition is based on the limitations of the range of motion of the cervical spine with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of the injury. The PEB and the VA both rated this condition at 20% and this rating is warranted based on cervical flexion of 30 degrees (>15 but ≤30) and combined cervical ROM of 165 (≤ 170 degrees).

Movement Cervical	Normal ROM	NARSUM (ROM not measured)	C&P Exam 20081115
Flex	0-45	--	30
Ext	0-45	--	15
R Lat flex	0-45	--	30
L lat flex	0-45	--	30
R rotation	0-80	--	30
L rotation	0-80	--	30
COMBINED	340	--	165
Notes:		Neck exam: normal appearance, essentially full active range of motion, 5/5 strength throughout, some mild tenderness to palpation was present at the bilateral cervical paraspinous muscles but no bony tenderness.	Joint function of the spine is not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.

Condition 2. Left Upper Extremity, Cervical Radiculopathy and Cervicalgia

The PEB did not make a fitness determination for this condition but radiation of pain into the left upper extremity was mentioned in the Medical Evaluation Board (MEB) Narrative Summary (NARSUM). The NARSUM does not include a specific arm examination but the musculoskeletal exam stated full range of motion and strength was normal throughout. No neurologic exam was documented. EMGs were done both before and after her surgery and neither showed any evidence of sensory or motor nerve impairment. The VA examination documented normal motor and sensory exams with the exception of abnormal coordination with the findings of dysesthesia (subjective) upon light touch in the left upper extremity. This would suggest a nerve involvement but EMG testing ruled this out. So while the CI does have pain radiating down her left arm, no radiculopathy is present. Also there does not appear to be any functional limitation as a result of the radiating pain. The CI was able to perform push-ups and could lift up to 40 pounds. The Commander’s letter does not mention any limitations due to arm pain.

There is no evidence of a sensory or motor cervical radiculopathy and no functional limitations of the left upper extremity. Radicular pain is included in the rating applied for neck pain. This condition is not considered unfitting for military service and no rating recommendation is made.

Condition 3 Lumbosacral Spine, Degenerative Joint and Disc Disease (Claimed as Backache)

The PEB did not make a fitness determination for this condition but it was mentioned in the NARSUM. A specific back exam was not documented but the musculoskeletal exam stated full range of motion and strength was normal throughout. The examination also documented a normal gait. The VA examination documented full ROM of the thoracolumbar spine without radiating pain, spasm, or tenderness and normal X-rays. There does not appear to be any functional limitation related to back pain. The NARSUM specifically states the restriction on running is secondary to the CI’s neck pain. Also she was able to do push-ups and sit-ups. The Commander’s letter does not mention back pain or any limitations that could be related to back pain.

There is no functional limitation related to back pain. This condition is not considered unfitting for military service and no rating recommendation is made.

Condition 4. S/P Hysterectomy

The PEB did not make a fitness determination for this condition but the surgery was mentioned in the NARSUM. There was no mention of problems related to the scar from this surgery. The NARSUM documents a normal abdominal examination and the CI’s profile did not restrict sit-ups or weight lifting. The VA abdominal examination is normal and notes the presence of scars.

There is no functional limitation related to s/p hysterectomy. This condition is not considered unfitting for military service and no rating recommendation is made.

Condition 5. S/P Cholecystectomy

The PEB did not make a fitness determination for this condition but the surgery was mentioned in the NARSUM. There was no mention of problems related to the scar from this surgery or any gastrointestinal complaints. The NARSUM documents a normal abdominal examination and the CI’s profile did not restrict sit-ups or weight lifting. The VA abdominal examination is normal and notes the presence of scars.

There is no functional limitation related to S/P Cholecystectomy. This condition is not considered unfitting for military service and no rating recommendation is made.

Other conditions

Postoperative Scar, Anterior Cervical Spine; Scar, Lower Abdomen, S/P Hysterectomy

The PEB did not make a fitness determination for these scars but the surgeries were mentioned in the NARSUM. The surgeries are mentioned in NARSUM but the scars are not specifically mentioned. Neck and abdominal exams did not mention scars or tenderness in the skin. There were no functional limitations that could be related to the scars and they are not considered unfitting. Therefore no rating is recommended.

Other conditions rated by the VA but not mentioned in the DES package (outside scope of PDBR):

Gastroesophageal Reflux; Status Post Nissen Fundoplication w/Hiatal Hernia Repair; History of Gastritis; Tinnitus; Left Ear Hearing Loss; Benign Paroxysmal Postural Vertigo; and S/P Left Ovarian Cyst

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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. After careful consideration of all available information, the Board unanimously recommends that the CI’s condition be rated at 20% for 5242 Neck Pain, Status Post C5-6 anterior Cervical Diskectomy and Fusion IAW the VASRD General Rating Formula for Diseases and Injuries of the Spine.

The CI’s cervical spine was limited to thirty degrees of flexion and the combined ROM of the cervical spine was 165 degrees. These findings warrant a 20% rating under the VASRD General Rating Formula for Diseases and Injuries of the Spine.

The Board considered the following conditions and unanimously concluded that none should be considered unfitting: Left Upper Extremity Radiculopathy; Lumbosacral Spine, Degenerative Joint and Disc Disease; S/P Hysterectomy; S/P Cholecystectomy; Postoperative Scar, Anterior Cervical Spine; and Scar, Lower Abdomen, S/P Hysterectomy. Only conditions that are considered unfitting for military service receive a rating recommendation.

The other diagnoses rated by the VA (Gastroesophageal Reflux; Status Post Nissen Fundoplication w/Hiatal Hernia Repair; History of Gastritis; Tinnitus; Left Ear Hearing Loss; Benign Paroxysmal Postural Vertigo; and S/P Left Ovarian Cyst) were not mentioned in the Disability Evaluation System (DES) package and are therefore outside the scope of the Board. The CI retains the right to request her service Board of Correction for Military Records (BCMR) to consider adding these conditions as unfitting.

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RECOMMENDATION: The Board therefore recommends that there be no recharacterization of the CI’s disability and separation determination.

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The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20090728, w/atchs.

Exhibit B. Service Treatment Record.

Exhibit C. Department of Veterans' Affairs Treatment Record.

Deputy Director

Physical Disability Board of Review

SAF/MRB

1535 Command Drive, Suite E-302

Andrews AFB, MD 20762-7002

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2009-00459.

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 with severance pay.

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

Director

Air Force Review Boards Agency

Attachment:

Record of Proceedings

cc:

SAF/MRBR