RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1201101 SEPARATION DATE: 20020613 

BOARD DATE: 20130308 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty, SPC/E-4, (11B/Infantryman), medically separated for 
back pain after a lumbar fusion. The CI developed back pain in the summer of 2000. He was 
treated conservatively, but his pain increased. Upon referral to Orthopedics, surgery was 
recommended. He underwent an L5-S1 posterior spinal fusion with instrumentation and 
posterior lumbar interbody fusion with Brantigan cage placement. Despite making some 
improvement, he continued to have significant pain and did not improve adequately to meet 
the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness 
standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board 
(MEB). The MEB forwarded no other conditions for Physical Evaluation Board (PEB) 
adjudication. The PEB adjudicated the back condition as unfitting, rated 10%, with application 
of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals, and 
was medically separated with a 10% disability rating. 

 

 

CI CONTENTION: “I have had continued pain that affects my ability to sleep and makes certain 
work activities more difficult due to standing or stooping. Pain will at times radiate into my hips 
and legs.” 

 

 

SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 
6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined 
by the PEB to be specifically unfitting for continued military service; or, when requested by the 
CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings 
for unfitting conditions will be reviewed in all cases. 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 IPEB – Dated 20020424 

VA (6 Mos. Post-Separation) – All Effective Date 20020614 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Back Pain 

5299-5295 

10% 

L4-L5 Spondylolithesis s/p fusion 

5299-5292 

10% 

20021227 

.No Additional MEB/PEB Entries. 

0% X 1 / Not Service-Connected x 0 

 

Combined: 10% 

Combined: 10% 



 

 

ANALYSIS SUMMARY: The Board utilizes VA evidence proximal to separation in arriving at its 
recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to 
post-separation evidence. The Board’s authority as defined in DoDI 6044.40, however, resides 
in evaluating the fairness of Disability Evaluation System (DES) fitness determinations and rating 
decisions for disability at the time of separation. Post-separation evidence therefore is 
probative only to the extent that it reasonably reflects the disability and fitness implications at 
the time of separation. 


Back Pain Condition. The 2002 VASRD coding and rating standards for the spine, which were in 
effect at the time of the CI’s separation, were updated 23 September 2002 for code 5293 
(incapacitating episodes), and then changed on 26 September 2003 to the current §4.71a rating 
standards. The 2002 standards for rating based on range-of-motion (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. VASRD normal ROM values were not 
in effect prior to 26 September 2003, and are for the combined thoracolumbar spine segment, 
whereas the older spine criteria considered the thoracic and lumbar spine segments separately. 
For the reader’s convenience, the 2002 rating codes under discussion in this case are excerpted 
below. 

 

5285 Vertebra, fracture of, residuals: 

With cord involvement, bedridden, or requiring long leg braces 100 

Consider special monthly compensation; with lesser 

involvements rate for limited motion, nerve paralysis. 

Without cord involvement; abnormal mobility requiring neck 

brace (jury mast)............................................ 60 

In other cases rate in accordance with definite limited motion 

or muscle spasm, adding 10 percent for demonstrable deformity of vertebral body. 

5292 Spine, limitation of motion of, lumbar: 

 Severe.......................................................................................40 

 Moderate..................................................................................20 

 Slight.........................................................................................10 

5293 Intervertebral disc syndrome: 

Pronounced; with persistent symptoms compatible with sciatic neuropathy with characteristic pain and 
demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to site of diseased 
disc, little intermittent relief....................................................... 60 

Severe; recurring attacks, with intermittent relief........... 40 

Moderate; recurring attacks................................... 20 

Mild.......................................................... 10 

Postoperative, cured.......................................... 0 

5295 Lumbosacral strain: 

 Severe; with listing of whole spine to opposite side, positive Goldthwaite's sign, marked limitation of forward 
bending in standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of 
joint space, or some of the above with abnormal mobility on forced motion............................................40 

With muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing 
position......................................................................................20 

 With characteristic pain on motion..............................................10 

 With slight subjective symptoms only............................................0 

 

The CI reported no specific direct or indirect history of back trauma. His low back pain (LBP) 
developed in the summer of 2000. Despite medication and physical therapy, his pain continued 
and worsened. Radiographic tests revealed an anterior wedge fracture and slippage of the fifth 
lumbar vertebra with disc involvement (wedge compression fracture of L5). An L5-S1 spinal 
fusion with instrumentation was performed 15 months prior to separation. Surgery was 
essentially uncomplicated and the CI continued post-operative physical therapy rehabilitation. 

 

At the MEB exam, 5 months prior to separation, the CI reported LBP exacerbated by standing 
greater than 15 minutes and the inability to perform sit-ups or push-ups. His running ability 
was reported as “at his own pace.” The CI was “noted to have good apparent ROM of the 
lumbar spine” with paraspinal muscle tenderness. Extension was 20 degrees (normal 25-30 
degrees), with all other ROMs at or above historic normal values. Post-operative imaging 
demonstrated good alignment and fusion with retained hardware. A PT examination in March 
2002, 3 months prior to separation, indicated full ROM of the lumbar spine and both lower 
extremities. At the VA Compensation and Pension (C&P) exam, 6 months post date of 
separation (DOS), the CI reported occasional back pain when he was up and walking for too 
long a time or if he was doing extraordinary lifting and carrying. Additionally, he reported 
infrequent (several times weekly), brief (lasting less than a second), sharp pain in the 
paravertebral area around the fifth lumbar vertebra. The examiner noted, the CI attributed 
these sharp pains to the screws in his low back. The C&P exam noted fullness as well as point 
tenderness to the surgical site consistent with implanted hardware. This was more notable on 


the right as compared to the left. There was normal ROM with painful motion greatest with 
extension and his gait was normal. VA radiographs (over 20 months after surgery) stated 
“There is wedging of L5. Trauma is an unusual cause for wedging of vertebrae at this level. We 
do not know the cause.” Retained hardware was noted and the impression also stated “Flexion 
and extension films show no movement between L4 and L5. Restricted movement between L5 
and S1. Normal movement above L4.” 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
IPEB rated the back at 10% analogous to 5295 (Lumbosacral strain; with characteristic pain on 
motion). The VA rating of 10% was under 5292 (Lumbar Spine, limitation of motion). The 
Board considered that spine extension was slightly limited at the MEB exam and there was 
insufficient evidence for moderate limitation of lumbar motion. There was insufficient 
evidence of a radiculopathy or symptoms compatible with a neuropathy for rating under 5293 
(Intervertebral disc syndrome) above 10% (mild) proximal to separation. The Board considered 
that there was slight limitation of lumbar motion (extension) supporting a 10% rating for slight 
limitation of lumbar motion under code 5292. There was also both pre-operative wedge 
fracture and post-operative evidence of demonstrable deformity of the L5 vertebral body that 
warranted adding 10% IAW VASRD 5285 (vertebra, fracture of, residuals) in effect at the time of 
separation. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 
(Resolution of reasonable doubt) and §4.7 (Higher of two evaluations), the Board recommends 
a disability rating of 20% (10% plus 10%) for the back pain (s/p fracture and fusion) condition 
coded 5285-5292. 

 

 

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 back 
pain condition and IAW the 2002 VASRD, the Board unanimously recommends a total disability 
rating of 20% coded 5285-5292 (10% plus 10%) IAW VASRD §4.71a. There were no other 
conditions within the Board’s scope of review for consideration. 

 

 

RECOMMENDATION: The Board recommends that the CI‘s prior determination be modified as 
follows, effective as of the date of her prior medical separation: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Back Pain After Lumbar Fusion 

5285-5292 

10%+10% 

Rating 

20% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120706, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

xxxxxxxxxxxxxxxxxxxxxxxxxx, DAF 

Acting Director 

Physical Disability Board of Review 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

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

 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation 

for xxxxxxxxxxxxxxxxxxxx, AR20130007805 (PD201201101) 

 

 

1. 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 to modify the individual’s disability rating to 20% without recharacterization 
of the individual’s separation. This decision is final. 

 

2. I direct that all the Department of the Army records of the individual concerned be corrected 
accordingly no later than 120 days from the date of this memorandum. 

 

3. I request that a copy of the corrections and any related correspondence be provided to the 
individual concerned, counsel (if any), any Members of Congress who have shown interest, and 
to the Army Review Boards Agency with a copy of this memorandum without enclosures. 

 

 BY ORDER OF THE SECRETARY OF THE ARMY: 

 

 

 

 

Encl xxxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)