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AF | PDBR | CY2012 | PD2012 00494
Original file (PD2012 00494.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: xx         CASE: PD1200494
BRANCH OF SERVICE: NAVY  BOARD DATE: 20130418
SEPARATION DATE: 20030317


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty AMAA/E2 (00168/Admin Clerk/Enlisted Evaluation/Manpower) medically separated for chronic regional pain syndrome (CRPS) and failed back surgery syndrome. The CI was involved in two separate injuries related to his neck and back. The first was from a fall in March 2001 and the second was from a motor vehicle accident (MVA) in July 2001. He reported upper back pain, neck pain and occipital pain after the MVA. He underwent a C5-6 laminectomy and foraminectomy in October 2001. He continued to complain of pain and was eventually diagnosed with regional pain syndrome (RPS). The pain/spine condition could not be adequately rehabilitated to meet the physical requirements of his rating or satisfy physical fitness standards. He was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB). CRPS was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. The MEB also identified and forwarded three other conditions (see rating chart below) for PEB adjudication. The Informal PEB (IPEB) adjudicated “chronic regional pain syndrome” and a related failed back surgery syndrome as unfitting, rated 20%, with likely application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be C ategory III cond i tions (not separately unfitting and do not contribute to the unfitting condition.) The CI made no appeals and was medically separated with a 2 0% disability rating.


CI CONTENTION: “Injuries are worse than when discharged and have limited life from all aspects. Neuropathy has caused increased pain. Migraine headaches have crippled my work career.”


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 CRPS condition is addressed below. The neuropathy symptoms will also be considered. The requested migraine headaches were not identified by the MEB/PEB, and thus is are not within the DoDI 6040.44 defined purview of the Board. The adjustment disorder with depressed mood, chronic narcotic use, and impaired mental status secondary to narcotics and opiates, identified as Category III conditions by the PEB, were not requested for review, and thus are not within the defined scope. The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications 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. The Board considers DVA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month 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. 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 Board for Correction of Naval Records.


 RATING COMPARISON :

Service IPEB – Dated 20030127
 VA - (STR)
Condition
 Code Rating Condition Code Rating Exam
Chronic Regional Pain Syndrome 5290 20% S/P Left Laminotomy/Foraminotomy of C5-6 with Radiculopathy 5237 0% STR
Chronic Narcotic Use Not Unfitting No VA Entry
Adj Disorder w/Depressed Mood Not Unfitting No VA Entry
Impaired Mental Status secondary to Narcotics and Opiates Not Unfitting No VA Entry
No Additional MEB/PEB Entries
 Other x 3 STR
Rating: 20%
 Rating: 0%
CI did not apply to the VA until March 2007. CI failed to show for first C&P. Rating s increase d after an exam in 2008.


ANALYSIS SUMMARY:

Chronic Regional Pain Syndrome and Failed Back Surgery Syndrome (related to DX 1). The CI was first seen on 5 March 2001, a week after accession, after he fell and hit his head while doing exercises. There was no loss of consciousness (LOC) and X-rays of the cervical spine (C-spine) were normal. He was seen five more times over the next 3 weeks complaining of headaches and numbness; his examination was normal as were repeat X-rays and a magnetic resonance imaging (MRI) exam of the C-spine. He was returned to full duty and completed basic training on 8 May 2001. He was able to complete an apprentice training as a helicopter mechanic and reported to his first duty station on 11 June 2001. On 4 July 2001, while on leave, he was involved in a single car MVA, but was able to drive the vehicle afterwards. There was no LOC and the air bag did not deploy. He was seen 2 days later in a local emergency room (ER) and complained of a headache. C-spine X-rays were normal. He was seen multiple times over the next few months complaining of persistent weakness and numbness of both upper extremities. His examination and range-of-motion (ROM) were normal, but his symptoms persisted despite light duty, traction in physical therapy (PT) and medications. He was evaluated by a neurologist on 28 August 2001 and found fit for duty. However, he presented to both flight medicine and an orthopedist with continued symptoms and continued on light duty. It was thought that he would not be able to participate in a scheduled 6 week deployment due to start on 11 September 2001. An MRI on 20 September 2001 revealed a small left lateral disc protrusion and compression of the left neural foramen at C5-6. He was referred to a neurosurgeon (NS) and underwent a C5-6 laminotomy and foraminotomy on 19 October 2001. He was discharged to convalescent leave. A post-operative MRI on 7 January 2002 noted an osteophyte off of the left C5 lamina with mild central canal narrowing without cord compression. A fluid collection, syrinx, was also noted. He continued to have pain and the convalescent leave was incrementally extended through the following August. An epidural steroid injection (ESI) provided no benefit nor did a facet block. Electrodiagnostic testing of the upper extremities, done on 19 February 2002 for possible weakness of the left deltoid and triceps, was normal. On 19 April 2002 he was begun on Methadone and Pamelor by the pain management clinic. On 7 May 2002, a LIMDU period of 8 months was recommended. A repeat MRI that day showed that the syrinx had resolved. No pathology was documented by the neurosurgeon. A neurology evaluation on 3 June 2002 noted reproducible trigger points consistent with a myofascial pain syndrome. Botox injections were done on 18 July 2002 with pain improvement. A week later, the neurosurgeon determined that there were no neurosurgical contraindications to return to full duty. The radicular symptoms were noted to have resolved. On 26 August 2002, the CI was admitted for observation after an apparently unintentional medication overdose. It was determined by the case manager that he did not meet retention standards and referred to a MEB. The narrative summary (NARSUM) was dictated on 4 September 2002 by internal medicine. It noted that the CI reported that his symptoms began in May 2001 after he fell about five feet out of a helicopter onto concrete, landing on his back. There were no contemporaneous records to support this history. Rather the record showed that his symptoms first developed in basic training after he fell and hit his head. A 23 December 2002 line of duty evaluation showed no record that the CI had been in a helicopter accident. The CI reported continued neck and back pain with intermittent loss of sensation and paresthesias of his hands. He reported bilateral leg weakness for which he used a cane and for walking over 15 minutes, a wheelchair. On examination, the left shoulder abduction was 4/5, but associated pronator drift was absent. There was no atrophy or fasciculations. The reflexes were normal and symmetric. Sensation was diminished in both hands and upper extremities. Although the CI used a cane, the gait was narrow. It was noted that there was no clear etiology for his pain which was refractory to multiple treatment modalities. A mental health addendum dictated 13 September 2002 showed a resolved adjustment disorder with no psychiatric impairment to duty. A pain management addendum on 29 October 2002 documented that the CI reported persistent neck and bilateral arm pain. On examination, he walked with a cane and was diffusely tender over the midline along the entire cervical spine and bilateral trapezius muscles. There were no trigger points and the neurological examination, including sensation, strength, and reflexes were normal. The NARSUM was re-dictated on 18 December 2002 by neurosurgery after the initial dictation was misplaced. It noted that his neurological examination had been intact the entire course of his treatment. Imaging failed to show a cause for the symptoms and no neurosurgical cause of the pain was in evidence. The first VA Compensation and Pension (C&P) examination was not performed until over 5 years after separation, reducing the probative value of this evaluation.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the CRPS and related failed back surgery syndrome at 20% using the 5290 code, limitation of motion of the cervical spine. The Board considered other coding options for the spine, but none provided a route to a higher rating than the 20% adjudicated by the PEB. The Board also considered code 5301 for a Group I muscle impairment, but again with no documented spasm and normal strength, there was no route to a higher evaluation. 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 myofascial pain syndrome with failed back surgery condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that any contended not unfitting conditions were not unfitting. In this case, the contended neuropathy condition was not specifically addressed by the MEB or PEB, but is a potential consequence of the C-spine surgery and is therefore considered by the Board. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The neuropathy condition was not specifically addressed in the record. While the NARSUM noted left shoulder weakness in abduction, there was no corresponding pronator drift. Electrodiagnostic testing had been normal. The final examination, accomplished in the pain management clinic, was normal with intact sensation, strength, and reflexes. The neuropathy condition was reviewed by the Board. The preponderance of evidence from the record is that a neuropathy condition did not exist at the time of separation. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to add neuropathy as an unfitting condition at separation and so no additional disability ratings are recommended.
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. In the matter of the CRPS and related failed back surgery syndrome condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended neuropathy condition, the Board unanimously agrees that it cannot recommend it for additional disability rating. 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 Regional Pain Syndrome and (related) Failed Back Surgery Syndrome 5290 20%
RATING
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120604, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




         xx
         Director of Operations
         Physical Disability Board of Review
MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
BOARDS

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref: (a) DoDI 6040.44
(b) CORB ltr dtd 19 Jun 13

In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their respective forwarding memorandum, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:
- x former USMC
- x former USMC
- x former USMC
- x former USN
- x former USMC
- x former USMC
- x former USN
- x former USMC


                                                      xxx
                                                     Assistant General Counsel
                                                      (Manpower & Reserve Affairs)

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