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AF | PDBR | CY2012 | PD2012 01515
Original file (PD2012 01515.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: xx         CASE: PD1201515
BRANCH OF SERVICE: navy  BOARD DATE: 20130515
SEPARATION DATE: 20020707


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PC3/E4 (Postal Clerk) medically separated for spondylolysis. She presented to the neurosurgery clinic in 2000 after a one year history of back pain. A CT scan confirmed a L5 pars defect. Despite surgical intervention the condition could not be adequately rehabilitated to meet the physical requirements of her Rating or satisfy physical fitness standards. She was placed on limited duty and referred for a Medical Evaluation Board (MEB). The low back pain (LBP) condition, characterized as “spondylolysis,” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. No other conditions were submitted by the MEB. The PEB adjudicated “spondylolysis” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals, and was medically separated.


CI CONTENTION: “chronic spondylolysis, incomplete fusion”


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. Ratings for unfitting conditions will be reviewed in all cases. The rated, unfitting spondylolysis condition meets the criteria prescribed in DoDI 6040.44 for Board purview. 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 20020312
 VA - (2 Mos. Post-Separation) -
Condition
 Code Rating Condition Code Rating Exam
Spondylolysis
 5295 10% Spondylolysis S/P Lumbosacral Fusion L4-S1 w/Dextroscoliosis 5293-5292 10%* 20020926
No Additional MEB/PEB Entries
 Other x 4 20020926
Combined: 10%
 Combined: 10%
Derived from VA Rating Decision (VARD) dated 20021030 ( most proximate to date of separation [DOS]). *40% awarded eff day after separation VARD 20020912 Notice of Disagreement.


ANALYSIS SUMMARY:

Back Condition. Service treatment records indicated a history of non-trauma related LBP beginning in early 2000, diagnosed as spondylolysis. The CI initially reported radicular symptoms that resolved but the LBP persisted. Magnetic resonance imaging reportedly demonstrated a midline disc bulge at L4-5, as well as an L5 pars defect. The CI underwent L5-S1 fusion surgery on 8 January 2001 without complication. On 17 May 2001, 4 months after surgery, a neurosurgery clinic note recorded that the CI was out of the post-operative back brace and back at work. On physical examination motor and sensory exams were normal. At the 1 August 2001 follow up visit with neurosurgery, nearly a year prior to separation, the CI reported she was doing much better than before the surgery and was ready to return to full duty. The physician indicated the CI could participate in full physical training. The following day the CI presented to clinic with report of burning/sharp pain in right hip/buttocks. Physical therapy progress noted a week later recorded normal gait, and normal motor/neurological exams with normal deep tendon reflexes. The 10 August 2001 neurology exam noted normal gait, and normal motor/sensory examinations. The neurologist indicated there was no evidence of radiculopathy or other focal neurological deficit. Orthopedic consult on 7 May 2002, recorded a normal gait, negative straight leg raise, and lumbar flexion of 60 degrees (normal 90). Treatment records recorded three entries documenting full range-of-motion (ROM), three entries recorded decreases in ROM: two of them indeterminate, the other recorded flexion of 60 degrees, both recorded 2 months prior to separation. There was no documented clinical evidence of spasms, incapacitating episodes, abnormal gait, neuropathy, muscle weakness, diminished sensation or asymmetrical reflexes reported in the treatment records. On the MEB narrative summary evaluation on 22 January 2002, approximately 6 months prior to separation, symptoms were noted to be persistent but improved. The CI reported she was able to perform her job as a mail handler as long as she did not have to do heavy lifting. The CI stated she was not capable of performing the required number of sit-ups to meet the physical training requirement because of pain. Physical examination revealed normal strength, intact sensation and normal reflexes bilaterally. ROM and gait were not recorded. At the VA Compensation and Pension (C&P) evaluation performed 26 September 2002, approximately 10 weeks after separation, the CI reported back pain with prolonged walking, standing, and sitting. But, she was taking no prescribed medication. On examination, gait was normal; the CI could heel toe walk without difficulty. ROM included forward flexion, 75 degrees. Reflexes were normal and there was no evidence of a neuropathy.

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the condition 10% for pain coded 5295 (lumbosacral strain). The VA initially rated 10%, citing slightly limited motion of the lumbar spine and lumbar lordosis (deformity of the spine) coded 5293-5292 limitation of forward flexion code 5237 (limitation of motion). The CI appealed and the rating was increased to 40% based on the original C&P examination, citing severe limitation of motion of the lumbar spine. 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 must correlate the above clinical data with the 2002 rating schedule which was in effect at the time of separation (applicable diagnostic codes include: 5292 (limitation of lumbar spine motion); 5293, (intervertebral disc syndrome), and 5295 (lumbosacral strain). The Board considered the rating under 5295, lumbosacral strain, and agreed there was pain supporting the 10%. There was insufficient evidence to support the higher rating of 20% since there was no evidence of spasms occurring on extreme forward bending and no documented clinical evidence of spasms in any record prior to separation. The Board noted the reduced ROM on the C&P evaluation was relatively consistent with the treatment records, although there were two entries supporting decreased ROM and two documenting normal ROM. After discussion, the Board agreed that the limitation of motion of the spine at the time of separation based on the treatment record and the C&P examination was slight; therefore, it would not support a higher rating of 20% under the 5292 code. The Board considered rating under code 5293, intervertebral disc syndrome. There was no evidence of ratable peripheral nerve impairment in this case, since no motor weakness was present and sensory symptoms had no functional implication. There was no evidence of incapacitating episodes for a higher rating under this code. The Board was unable to find any pathway to a higher rating under any applicable VASRD code.


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 spondylosis 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
Spondylolysis
 5295 10%
COMBINED
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120817, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record





                  xx
                  President
                  Physical Disability Board of Review

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