RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE: PD1200971 SEPARATION DATE: 20030606 

BOARD DATE: 20130306 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SFC/E-7 (63E40/M1A2 Tank Maintenance Supervisor) 
medically separated for a lumbar spine condition. He developed radiating low back pain (LBP) 
in 1998 which was subsequently diagnosed as degenerative disc disease (DDD) requiring 
surgical intervention. Surgical response was initially satisfactory, but symptoms escalated in 
2001 and were associated with persistent bilateral foot numbness. The condition could not 
adequately rehabilitated to meet the physical requirements of his Military Occupational 
Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent P3/L3 profile 
and referred for a Medical Evaluation Board (MEB). Two diagnoses, “severe lumbago” and 
“bilateral foot sensory loss,” were forwarded to the Physical Evaluation Board (PEB) as 
medically unacceptable in accordance IAW AR 40-501. No other conditions were submitted by 
the MEB. The PEB adjudicated the separate MEB diagnoses as a single unfitting condition, 
characterized as “chronic back pain, status post L5-S1 fusion with lower extremity neuropathy 
manifested by numbness and absent right Achilles reflex;” rated 20% with likely application of 
the US Army Physical Disability Agency (USAPDA) pain policy or AR 635-40. The CI applied for 
Continuance on Active Duty as an exception to policy under the provisions of Chapter 6, AR 
635-40, Physical Evaluation for Retention, Retirement, or Separation. The U.S. Army Physical 
Disability Agency (USAPDA) did not favorably consider the request and the CI was medically 
separated with a 20% disability rating. 

 

 

CI CONTENTION: The application states simply, “L5 laminectomy with bilateral inferior 
facetectomy and L5-S 1 fusion using Ray threaded fusion cages and autologous iliac crest graft: 
20 January 1998.” The CI does not elaborate further or specify a request for Board 
consideration of any additional 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 those conditions identified but not determined to be unfitting by 
the PEB when specifically requested by the CI. The rating for the unfitting lumbar spine 
condition (with associated radiculopathies) 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 Army Board for Correction of Military Records. 

 

 

 

 

 

 

 

 

 

 


RATING COMPARISON: 

 

Service IIPEB – Dated 20030324 

VA - (1 Mo. Pre-Separation) VARD 20030707 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Chronic Back Pain, Status 
Post L5-S1 Fusion with 
Lower Extremity 
Neuropathy Manifested 
by Numbness and Absent 
Right Achilles Reflex 

5299-5295 

20% 

Status post L5-Sl Fusion 

5295 

20% 

20030502 

Bilateral Foot Sensory 
Loss 

Subsumed Above 

Radiculopathy Right Foot 

8599-8520 

10% 

20030502 

Radiculopathy, Left Foot 

8599-8520 

0% 

20030502 

No Additional MEB/PEB Entries 

Other Conditions X 12 

20030502 

Combined: 20% 

Combined: 70%* 



Derived from VA Rating Decision (VARD) 20030707 (most proximate to date of separation) 

 

ANALYSIS SUMMARY: 

 

Lumbar Spine Condition. The medical records show intermittent conservative treatment (non-
steroidal anti-inflammatory medications, physical therapy, and profiling) for LBP from 1992 up 
to 1997 due to training injuries. In 1997 his LBP recurred with radiation and paresthesias into 
both lower extremities and associated night pain. Orthopedics evaluated him and reviewed X-
rays which revealed grade I L5-S1 spondylolisthesis with bilateral L5 spondylolysis and referred 
him to an orthopedic spine surgeon. The spine surgeon initially recommended conservative 
treatment. Five months later he developed weakness of the right foot with decreased 
sensation, consistent with L5 dermatome, and diminished right ankle reflex. A magnetic 
resonance imaging (MRI) exam confirmed L5-S1 DDD and spondylolysis with pars defect and 
thus the CI underwent L5-S1 instrumented fusion surgery in January 1998 for refractory pain 
and progressive symptoms. The post surgical and rehabilitation period were without 
complications. The CI noted some foot numbness postoperatively; however he was performing 
his duties with a P2 profile for status post (s/p) spine fusion that limited only sit-ups. The 
record was silent for treatment from August 1999 until February 2001 when he sought care for 
recurrence of LBP and he occasionally needed a narcotic based pain medication for acute flares. 
A repeat MRI revealed; L4-L5 herniated nucleus pulposus (HNP, herniated disc), DDD, and 
spondylolysis with no significant narrowing, and s/p bilateral laminectomy procedure at the L5-
S1 with no spinal stenosis. A new permanent profile was issued in October 2002 for s/p spinal 
fusion with hardware implantation with more restrictive limitations to include no tactic 
vehicles, ruck march or sit-ups, no crawling and no stooping. The profile allowed a bending 
time limit of 30 minutes, alternate event for physical fitness testing and use of cane and back 
brace as needed. The commander’s statement corroborated the medical condition and 
additionally documented the CI was assigned to administrative duties. The commander further 
opined the CI could continue to perform in his MOS if assigned in units; that did not require 
operations on military vehicles and urged his retention on active duty in a duty position 
appropriate to his profile. 

 

The narrative summary (NARSUM), 8 months prior to separation, demonstrated; normal range-
of-motion (ROM), motor strength 5 of 5 bilaterally in the upper & lower extremities; subjective 
decreased to pinprick in the right L5 and left S1 dermatomes, absent right ankle jerk and 
otherwise normal neuromuscular findings, antalgic but not ataxic station and gait, negative 
straight leg raise (SLR) bilaterally (provocative testing for disc disease), a well healed scar, and 
no Waddell's signs. X-rays revealed s/p L5-S1 fusion with no instability, hardware failure, or 
impingement. The examiner opined the LBP was moderate and constant. At the VA 
Compensation and Pension (C&P) exam performed a month prior to separation, the CI reported 
5 of 10 constant dull LBP that increased to an 8-9 of 10 sharp pain two times per week with 
normal daily activity. The pain subsided in one day after treatment with nonsteroidal anti-


inflammatory and narcotic based pain medication. Associated symptoms included radicular 
pain to the bilateral legs down to the feet two times per month and constant numbness of the 
bilateral feet. His reported daily activity limitations included could not; lift greater than 20 
pounds, stand greater than 15-20 minutes at a time, run or perform jarring activities. The C&P 
exam demonstrated normal painful ROM, normal posture and gait, bilateral numbness, absent 
right Achilles' reflex and normal motor strength, bilaterally. X-rays revealed moderate 
osteophytosis, and moderate disk protrusion with degenerative spondylosis. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB and VA based their rating recommendations IAW 2002 VASRD coding and rating standards 
for the spine, which were in effect at the time of separation, were modified on 23 September 
2002 to add incapacitating episodes (5293, Intervertebral disc syndrome), and then changed to 
the current §4.71a rating standards on 26 September 2003. The 2002 standards for rating 
based on ROM impairment were subject to the rater’s opinion regarding degree of severity, 
whereas the current standards specify rating thresholds in degrees of ROM impairment. Both 
the PEB and the VA rated the CI’s lumbar spine condition at 20% coded 5295. The Board notes 
the NARSUM is absent for muscle spasm or loss of lateral spine motion which allows for a 20% 
5295 rating, however the Board's recommendation may not produce a lower rating than that of 
the PEB. The Board considered a rating under the 5292 code for limitation of spine motion. 
Neither the MEB nor the VA normal ROM’s documented would justify a “moderate” 20% rating 
under that code. There is no evidence of documentation of incapacitating episodes to meet 
criteria under the 5293 code which would provide for a higher rating. The Board also 
considered whether an additional rating for sciatic radiculopathy, as conferred by the VA, was 
appropriate in this case. Board precedent is that a functional impairment tied to fitness is 
required to support a recommendation for addition of a peripheral nerve rating at separation. 
The sensory component in this case has no functional implications. Furthermore, after the 
spinal fusion and prior to separation there is no physical finding of motor weakness to consider 
for significant functional impairment. All members agreed, therefore, that a recommendation 
for additional rating based on peripheral nerve impairment is not supported. After due 
deliberation, considering all of the evidence and mindful of VASRD §4.3 (Resolution of 
reasonable doubt), the Board concluded that there was insufficient cause to recommend a 
change in the PEB adjudication for the low back pain 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. As discussed above, likely PEB reliance on the USAPDA pain policy or AR 635-
40 for rating lumbar spine condition was operant in this case and the condition was adjudicated 
independently of that policy or instruction by the Board. In the matter of the lumbar spine 
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 recharacterization of 
the CI’s disability and separation determination, as follows: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Chronic Back Pain, Status Post L5-S1 Fusion with Lower Extremity 
Neuropathy Manifested by Numbness and Absent Right Achilles 
Reflex 

5299-5295 

20% 

COMBINED 

20% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120609, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 xxxxxxxxxxxxxxxxxxxxxx, DAF 

 Acting Director 

 Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

(TAPD-ZB / xxxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for 
xxxxxxxxxxxxxxxxxxxxxxxxxxx, AR20130007520 (PD201200971) 

 

 

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 xxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)