RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXX CASE: PD1201770 

BRANCH OF SERVICE: ARMY BOARD DATE: 20130319 

SEPARATION DATE: 20020906 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SGT/E-5 (91W/Health Care Specialist) medically 
separated for a lumbar spine condition. He developed radiating low back pain (LBP) 4 years 
prior to separation; was diagnosed with lumbar disc disease; and, underwent surgical 
intervention in 2002. His back and radicular pain did not respond adequately to surgery 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 lumbar disc condition was forwarded to the Physical Evaluation Board (PEB) 
as two diagnoses (“failed back syndrome” and “status post L4-5 laminotomies and 
diskectomies”) characterized as medically unacceptable IAW AR 40-501. Two additional 
conditions, as identified in the rating chart below, were addressed by the MEB and forwarded 
as medically acceptable. The PEB appropriately combined the separate lumbar diagnoses as a 
single unfitting condition (“chronic back pain, status post L4-5 laminotomies and discectomy, 
without neurologic abnormality”) rated 10%; citing criteria of the Veterans Administration 
Schedule for Rating Disabilities (VASRD), but also referencing Department of Defense 
Instruction (DoDI) 1332.39 and Army Regulation (AR) 635-40. The CI made no appeals, and was 
medically separated with a 10% disability rating. 

 

 

CI CONTENTION: The application states simply, “Chronic insomnia due to back pain & tinnitus 
back pain & tinnitus have worsened substantially” 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 is addressed below. The requested insomnia and tinnitus conditions were not 
identified by the PEB, and thus are not within the DoDI 6040.44 defined purview of the Board. 
The lipid and hypertension conditions, identified as not unfitting by the PEB, were not 
requested for review and are thus not within the defined scope. Those, and any other 
conditions or contention not requested in this application, remain eligible for future 
consideration by the Army Board for Correction of Military Records. The Board acknowledges 
the CI’s information regarding the significant impairment with which his service-connected 
conditions continue to burden him; but, must emphasize that the Disability Evaluation System 
(DES) has neither the role nor the authority to compensate members for anticipated future 
severity of conditions resulting in medical separation. That role and authority is granted by 
Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws. 
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. 

 

 

 

 


RATING COMPARISON: 

 

Service IPEB – Dated 20020819 

VA - (6 Weeks Pre-Separation) 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Chronic Back Pain 

5299-5295 

10% 

Degenerative Disc Disease, Lumbar 

5293 

10% 

20020729 

Hyperlipidemia 

Not Unfitting 

No VA Entry 

Hypertension 

Not Unfitting 

Hypertension 

7101 

0% 

20020729 

No Additional MEB/PEB Entries 

Other x 0 

20020729 

Combined: 10% 

Combined: 10% 



VARD 20020909 (most proximate to Date of Separation) noted 5 conditions as not service connected and deferred one 
condition. Deferred condition (hearing) was awarded 0% by 20030624 VARD. 

 

 

ANALYSIS SUMMARY: 

 

Chronic Back Pain, Status Post L4-5 Laminotomies and Disectomy. The 2002 Veteran 
Administration Schedule for Rating Disabilities (VASRD) coding and rating standards for the 
spine, which were in effect at the time of permanent separation, were changed to the current 
§4.71a rating standards on 26 September 2003, following the CI’s permanent disability 
disposition. The older ratings were based on a judgment as to whether the disability was mild, 
moderate or severe. The current standards are grounded in range-of-motion (ROM) 
measurements. IAW DoDI 6040.44, this Board must consider the appropriate rating for the CI’s 
back condition at separation based on the VASRD standards in effect at the time of separation. 
The CI underwent surgery in January 2002 for symptoms of LBP and pain that radiated to the 
buttocks and lower extremities caused by an L4-5 disc bulge and bilateral foraminal narrowing. 
X-rays of the lumbar spine in April 2002 showed no abnormalities. A magnetic resonance 
imaging (MRI) in May 2002 showed no evidence of recurrent disc protrusion, although the 
radiologist opined that the S1 nerve root was possibly displaced due to granulation tissue 
resulting from the surgery. At the narrative summary (NARSUM) exam in June 2002, 3 months 
prior to separation, the CI reported alleviation of his pre-surgical leg pain and intermittent 
buttock pain, but back pain was severe; the buttock pain was increased when standing for more 
than 5-10 minutes. The examiner noted ROM “limited to less than 90 [degrees],” with normal 
strength, sensation, and reflexes. At the VA Compensation and Pension (C&P) exam in July 
2002, 6 weeks prior to separation, the CI reported buttock, hip, and lower back pain, with 
improvement of numbness and tingling in his buttocks, hip, and right lower extremity. Back 
pain severity was 6 on a 1-10 severity scale and buttock pain 2-3/10. He described subjective 
guarding when lifting greater than 20-25 pounds. The examiner noted tenderness over T10-L5. 
Gait and posture were normal, and muscle strength was normal throughout. The straight leg 
test was negative for radicular pain bilaterally. ROM was "full throughout" except for 
extension, which was limited to 10 degrees (30 degrees is normal by current standards). 
Lumbar X-rays were normal. The examiner noted a new history of episodic difficulty 
maintaining an erection and no objective exam findings. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB assigned a 10% rating under analogous code 5299-5295 (lumbar strain; mild “characteristic 
pain on motion”). The VA’s 10% rating was based on the 5293 code (intervertebral disc 
syndrome) for "mild" symptoms. The Board agreed that criteria for the next higher 20% rating 
were not in evidence under the 5292 (spine, limitation of motion, lumbar), 5293 or 5295 codes. 
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 chronic 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. As discussed above, PEB 
reliance on DoDI 1332.39 for rating 5295 was operant in this case and the condition was 
adjudicated independently of that instruction by the Board. In the matter of the chronic back 
pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the 
PEB adjudication. 

 

 

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 

5299-5295 

10% 

COMBINED 

10% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120929, 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 / xxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for 
xxxxxxxxxxxxxxxxxxxxxxxxx, AR20130007489 (PD201201770) 

 

 

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 xxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)