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AF | PDBR | CY2012 | PD 2012 01637

Original file (PD 2012 01637.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXX CASE: PD-2012-01637
BRANCH OF SERVICE: AIR FORCE BOARD DATE: 20140910

SEPARATION DATE: 20030203

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated reserve SSGT/E-5 (1T2X3/Pararescue) medically separated for a neck condition. The neck could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards. He was issued a temporary P3 profile and referred for a Medical Evaluation Board (MEB). The neck condition, characterized as “cervical herniated nucleus pulposus [HNP] with myelopathy (early) due to C4-5 disc protrusion and cervical radiculopathy due to the C6-7 disc bulge,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. The Informal PEB adjudicated “C4-5 herniated nucleus pulposus and C6-C7 bulge with early myelopathy, status post foraminotomy, Aug 2000,” as unfitting, rated at 10%, with a pplication of the VA Schedule for Rating Disabilities (VASRD). The CI non-concurred with the IPEB findings/recommendations, and requested Formal PEB (FPEB), who re-adjudicated the CI’s neck condition increasing the rating from 10% to 20%. The CI non-concurred with the FPEB findings/recommendations further appealed to the Air Force Board of Correction of Military Records (AFBCMR). The AFBCMR identified the condition as a combat-related disability, but affirmed the FPEB’s 20% rating. The CI made no further appeals was then medically separated. The CI submitted additional clinical documentation to the Physical Disability Board of Review (PDBR), which was reviewed and deliberation by the Board for its findings and recommendations.

CI CONTENTION: The CI writes: “Besides the met that the VA rated my condition Degenerative Joint Disease, Cervical Spine with stenosis C3-C4-C5 at 30%. Which is effectively 42% of my cervical spine has some type of damage or disease. Then the board failed to acknowledge the Neuritis in the left upper extremity and left chest associated with degenerative joint disease, cervical spine, with stenosis, C3-C4-C5 Post Foraminotomy. As l point out several times. The VA rated this condition at 10%. If the board thinks this will resolve then TDRL should have been ordered. It was not if the board was looking at me as a whole person instead of parts they should have also taken a look at my R shoulder. Since in there [sic] eyes my nerve condition will resolve the spasms, weaknees, atrophy and craps will heal in time. (It has not) Now that they would be asking me to use my R shoulder more. FYI R shoulder is rated at 20% for dislocation and impingement syndrome. At that time PTSD wasn't even talked about or looked at as a factor. I have a VA rating for that at 30%. The Board even says in the Remarks section that this case warrants further discussion. The Board even mentions that limited neck motion, muscle spasms, limited daily activities support contention. Try being a PARARESUMAN with these issues!!! My paper Work [sic] had several errors also. Box 12. Flying status is marked no. It should be yes I am a PJ. I sent in this information for a correction, not sure if that ever took place. Box 11. Aeronautical rating is marked N/A. Again I am a Pararescue man my rating should have been basic air crew. Box 11 Compensable Percentage is marked 20% it should be somewhere between 40 to 70%. Box 12 Recommended Disposition should have been medical discharge. When I was paid my Severance pay was taxed. Not sure that is correct due to how injury happened. Instrumentality of War, Hazardous duty, Training simulating war aka combat equipment jump.”

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 neck condition is addressed below; there were no additional conditions 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 AFBCMR.

The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on severity at the time of separation. The Board considers DVA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-months interval for special consideration to post-separation evidence. Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation. The Board received and reviewed the additional information the CI submitted referencing recent medical exams and treatment; however, this information was determined to be of minimal probative value as it was remote from the date of separation.

RATING COMPARISON :

Service FPEB – Dated 20021025	VA - (15 Mos. Pre-Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
C4-5 Herniated Nucleus Pulposus and C6-C7 Bulge with Early Myelopathy, S/P Foraminotomy Aug 2000	5290	20%	Degenerative Joint Disease, Cervical Spine, S/P Foraminotomy with History of Congenital Stenosis at C3-4-5	5293-5290	30%	20011106
Other x 0 (Not in Scope)	Other x 6 (Not in Scope)	Various
Combined: 20%	Combined: 60%

* Derived from VA Rating Decision (VA RD ) dated 200 21116 ( most proximate to date of separation )

ANALYSIS SUMMARY:

C4-5 Herniated Nucleus Pulposus and C6-C7 Bulge with Early Myelopathy, Stats Post Foraminotomy. The CI initially injured his neck during a parachute jump in April 2000 and developed neck pain, which radiated into the left arm consistent with a left C7 spinal nerve root radiculopathy without weakness or sensory changes on examinations. A diagnostic magnetic resonance imaging (MRI) and computed axial tomographic myelogram of the cervical spine demonstrated a herniated intervertebral disc at the C6-7 level impinging the left C7 spinal nerve root. The imaging also demonstrated small disc bulges at C3-4, C4-5 and C5-6 which made contact with the outer layer of the spinal cord (thecal sac) without compressing the spinal cord or other spinal nerve roots.

The CI underwent a foraminotomy in June 2000 to enlarge the bony space around the left C7 nerve root without removal of the disc. Post-operative treatment records indicate improvement in symptoms. A follow-up neurology appointment dated 5 January 2001 (6 months post-surgery); the CI reported neck pain with lateral bending, left triceps weakness and muscle spasms. The CI also reported headaches while exercises that involved lifting 100 pounds or performing sit-ups. On examination, the examiner noted mild left triceps weakness, deep tendon reflexes (DTRs) were increased and gait was normal. The neurologist noted the small spinal canal space with bulging discs making contact to the outer layer of the spinal cord, and advised against activities that risked neck injury (e.g. parachute jumping, contact sports, etc.). The neurologist also recommended consideration of a more extensive cervical spine surgery (laminectomy). An MRI obtained on 27 June 2001, a year after foraminotomy, demonstrated congenital spinal canal narrowing (stenosis) from C3 to C7 which became more significant secondary to degenerative changes resulting in mild spinal cord compression at C3-4, C4-5 and C5-6 without abnormal MRI signal changes to indicate spinal cord injury. During a follow-up appointment with his spinal surgeon on 24 July 2001, the CI stated he had good relief of arm symptoms but persistent pain in his neck and shoulders. On examination, the neck flexed to 40 degrees (normal 45) and extended 20 degrees (normal 45), sensation/strength in the left arm were normal and DTRs were intact and symmetric. The spine surgeon reviewed the MRI scans and concluded there were no disc protrusions that appeared to significantly compress either nerve roots or spinal cord (noting normal signal intensity in the spinal cord). Surgery was not recommended by the spinal surgeon at that time. A later follow-up appointment with his neurologist on 26 July 2001, the CI’s strength had increased considerably since January 2001, due to swimming and working out in the gym. More physical strain was required to produce symptoms of tingling in the left hand fingers (ring and little). There was complaint of right neck pain and right shoulder and arm aching. On examination, the examiner observed that the CI was “very fit”, his neck motion was “limited”, and strength / reflexes were normal bilateral arms. There were some paresthesia in the left ring and little fingers but sensation was otherwise intact. A neurology appointment dated 21 September 2001 recorded similar findings.

At the VA spine Compensation and Pension (C&P) examination performed on 6 November 2001, the CI reported neck pain radiating to the left arm with tingling in the hand in an ulnar nerve distribution (little and ring fingers). The CI also reported headaches associated with the neck pain and frequency of pain flare-ups as often as 4 to 6 days per week with additional loss of motion. On examination, the examiner noted neck flexion of 20 degrees (normal 45), extension of 20 degrees (normal 45), lateral flexion of 15 degrees to sides (normal 45), rotation of 50 degrees to the left and 40 degrees to the right (normal 80). DTRs were indicated as increased on the left with decreased sensation in a left ulnar nerve distribution and weakness of the biceps muscle, triceps muscle and grip.

The commander’s letter, dated 16 April 2002, stated that the CI was able to work “full shifts”, ability to perform duties that were not physically demanding, and goes on to recommend the CI’s retention in more a sedentary role such as administrative, logistic, supply and maintenance support.

The MEB narrative summary, prepared on 27 June 2002 by an Air Force neurosurgeon, noted significant improvement in pain and weakness following surgery but continued problems with muscle spasms in the left pectoralis and triceps muscles with tingling of ulnar aspect of left hand. The CI also reported sub-occipital headaches and locking of the neck with certain movements. The CI stated that his symptoms were aggravated by activity; interfere with school and administrative duties at work. On examination, the examiner observed the CI’s gait and coordination were normal, experience neck pain with pressing down on the head. Neck motion was “limited” but no further details were provided. Muscle strength was normal except for slight left triceps muscle weakness (straightens the elbow), atrophy (decreased muscle bulk) and DTRs were hyperactive; without radicular signs and symptoms with provocative maneuver. The neurosurgeon noted the results of the MRI study that was obtained on 26 June 2002 and concurred with diagnosis of cervical HNP with myelopathy (early) due to C4-5 disc protrusion and cervical radiculopathy (C7) due to C6-7 bulge versus residual permanent left C7 root damage from the prior large disc herniation.

Following the IPEB, the CI a sought second opinion from an independent neurologist and was evaluated on 10 October 2002. During this examination the CI reported ongoing tingling and spasms in the left hand (in a distribution of the C8 nerve root), twitching in the triceps, weakness in the pectoral group, ongoing headaches, limited range-of-motion and constant neck, left arm and headache pain. Due to the symptoms, the CI reported he was unable to perform his MOS duties and the inability to work his own ranch. The CI goes on to further state that the pain interfered with his ability to concentrate and complete course assignments (enrolled in college classes) and also the inability to participate in sporting activities he previously enjoyed for fear further injuring his neck. The CI reported some tingling in his feet but no lower extremity weakness and no bowel or bladder function changes. On examination, neck flexion was “preserved” but decreased with both extension and lateral flexion. Upper extremity muscle bulk, tone and power were “preserved” but the CI reported that he perceived asymmetry in strength. DTRs were hyperactive (suggestive of spinal cord compression with myelopathy). Coordination and gait were normal. There were sensation changes in the left extremity in an approximate to C7 and C8 pattern. The neurologist concluded there was cervical radiculopathy with pain, numbness and subjective but not objective weakness corresponding to C7 and C8 levels; also noted there was evidence of mild cervical myelopathy. He concluded with a request in the CI’s favor of a 100% disability rating determination.

A month post separation, a neurology examination performed on 6 March 2003 the CI reported persistent left arm radicular pain with sensory changes in C7 distribution. On examination, the neurologist observed the CI was “very fit” in appearance with “limited” neck motion, mild weakness of the left triceps muscle, pectoralis muscle and grip. The neurologist stated that a recent MRI study (date omitted) revealed moderate cervical canal stenosis without abnormal signal changes in the spinal cord that would indicate injury. An MRI performed on 16 June 2003, demonstrated similar findings from a prior MRI study, showing mild cord compression at C4-5, without abnormal signal in cord. A bilateral upper extremities electromyogram study conducted on 9 April 2003 was normal, the electromyogram showed no changes of motor neuron injury from cervical radiculopathy or myelopathy. The examiner also recorded left upper arm girth of 335 millimeters and right upper arm girth of 338 millimeters (an insignificant difference indicating no significant atrophy).

The VA C&P examination performed on 2 March 2004 (approximately a year post separation), the CI’s reported having muscle spasms of the left pectoralis muscle since his neck surgery, but denied weakness of the upper extremities. The examiner noted the CI stated that he wore a knee brace while engaging in sports or heavy physical activities but denied limitations with walking. On examination, the cervical spine flexion was 55 degrees, extension was 25 degrees, had a left lateral bending of 25 degrees, right lateral bending of 30 degrees, left rotation of 60 degrees and a right rotation of 50 degrees. Strength was indicated as normal and without atrophy. There was no tenderness or muscle spasm noted. The left upper arm circumference was 34 centimeters while the right was 35 centimeters. There was decreased sensation of the left hand ring and little fingers. The examiner concluded that the CI’s left arm, left chest and left hand symptoms were residuals of neuritis from prior nerve involvement due to his cervical spine condition.

The Board directs attention to its rating recommendation based on the above evidence. The FPEB adjudicated a 20% rating coded under 5290 (limitation of cervical spine motion), concluding that the threshold for additional rating under VASRD code 8510 (paralysis of the upper radicular group) was not supported by the preponderance of evidence. The VARD dated 16 November 2002, rated the neck condition at 30%, under code 5293-5290 (intervertebral disc syndrome-limitation of cervical spine motion), citing the November 2001 VA C&P examination which reported the CI had severe limitation of motion during periods of flare-ups. The subsequent VARD dated 4 June 2004 cited the VA C&P examination (performed on 2 March 2004), stating that the threshold for a higher rating of 30% was not met but granted the 30% rating. Similarly, the September 2011 VARD cited the VA C&P examination (performed on 19 October 2010) would warrant a 10% rating but again adjudicated a 30% rating. The claimed neurologic condition for the left arm, hand and upper chest region was not granted as separate rating by the VARD in November 2002. The VARD dated 11 May 2004, subsequently granted a 10% rating for neuritis, for left upper extremity and left chest associated with cervical spine stenosis under VARSD code 8616 (neuritis ulnar nerve), based on the March 2004, VA C&P examination.

In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation. The Board notes that the 2002 VASRD standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards in 2004. The Board must correlate the above clinical data with the 2002 rating schedule (applicable diagnostic codes include: 5290 (limitation of cervical spine motion) and 5293 (intervertebral disc syndrome), interim guidelines based on incapacitating episodes). The Board agreed the limitation of cervical spine motion documented prior to separation more nearly approximated the moderate (20%) than slight limitation (10%) under the VASRD 5290 guidelines in effect at the time of the CI’s separation, but did not support a rating higher than the 20% adjudicated by the PEB. The Board noted post-separation examinations with improvement, which were consistent with a 10% rating. The Board noted the VARD citing severe limitation during flares recorded in the November 2001, VA C&P examination. However, this was not corroborated in the service treatment records prior to the time of the MEB. The Board therefore concluded the preponderance of evidence did not support a rating higher than the 20% rating adjudicated by the FPEB.

The Board further noted there were no incapacitating episodes (physician prescribed bed rest) to support consideration of a minimum rating under code 5293. The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy. The CI had a herniated C6-7 disc causing left C7 radicular symptoms. Following surgery the symptoms improved except for mild to minimal subjective weakness of the left triceps and tingling of the ring and little fingers (ulnar nerve distribution). While some examinations such as the November 2001, VA C&P examination, indicated mild weakness, most other examinations recorded normal strength. In addition, the CI had cervical spinal stenosis due to the combination of a developmentally narrow spinal canal and degenerative disc disease with bulging discs at several levels in the cervical spine. Although the hyperactive reflexes on examination suggested myelopathy (compression of the spinal cord), MRI findings did not show signal changes in the spinal cord indicating injury and there was no weakness or coordination problems including of the lower extremities.

The Board also noted the electromyogram obtained 2 months post separation, which demonstrated no evidence of abnormal motor nerve function (from radiculopathy or myelopathy) of cervical spinal nerve roots. The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting. Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation specific activities. There is no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing. The Board therefore concludes that additional disability rating was not justified on this basis. The Board also noted the advice to avoid activities which put the CI at risk for sudden forces on the neck which might result in compression of the spinal cord (such as parachute jumping) however future risk is not ratable. The Board also noted the condition remained stable based on VA exams through 2010. 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 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. In the matter of the cervical spine herniated disc 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 20120904, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAF/MRB

XXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXX:

         Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2012-01637.

         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,

XXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

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AF | PDBR | CY2012 | PD 2012 01637

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