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AF | PDBR | CY2012 | PD2012 01647

Original file (PD2012 01647.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX CASE : PD12 0 1647
BRANCH OF SERVICE: AIR FORCE BOARD DATE: 201 4 0117

Separation Date: 20031214

SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an Air National Guard member, SSgt/E-5 (1C551/Journeyman Aerospace Control and Warning Systems Operator), medically separated for a chronic low back pain (LBP) status post (s/p) lumbar fusion. The CI had a lengthy history of LBP of idiopathic origin, which did not respond to conservative treatment. He underwent a lumbar fusion and despite further rehabilitation and treatment, he could not adequately meet the physical requirements of his Air Force Specialty (AFS) or satisfy physical fitness standards. He was consequently issued a temporary P4 profile and referred for a Medical Evaluation Board (MEB). The chronic LBP s/p lumbar fusion, characterized as the same, was forwarded to the Informal Physical Evaluation Board (IPEB). Adjustment disorder with anxious mood was identified by the MEB and also forwarded to the IPEB. The IPEB adjudicated the chronic LBP s/p lumbar fusion as unfitting, rated 10%, citing the Veterans Affairs Schedule for Rating Disabilities (VASRD) and DoD guidelines. The IPEB found the adjustment disorder with anxious mood as Category III (a condition that is not separately unfitting and not compensable or ratable). The CI appealed to a Formal PEB (FPEB). The FPEB adjudicated the chronic LBP s/p lumbar fusion as unfitting and rated at a 20%. The FPEB affirmed the IPEB finding with respect to the CI’s adjustment disorder with anxious mood. The CI made no further appeals and was medically separated.

CI CONTENTION : The application simply states “Back”. The CI does not elaborate further or specify a request for Board consideration of any additional conditions.

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 rating for the unfitting LBP is addressed below. The adjustment disorder was not requested or alluded to in the application and is judged to have not been requested; e.g., it does not satisfy scope requirements. 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 the Correction of Military Records.

RATING COMPARISON :

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Service FPEB – Dated 20030917	VA (# Mo. Post-Separation) – Effective 20031215
Condition	Code	Rating	Condition	Code	Rating	Exam
Chronic LBP S/P Lumbar Fusion	5295	20%	s/p Lumbar Fusion L4-5; L5-S1	5242	20%	20040625
Adjustment Disorder with Anxious Mood	Category III	Adjustment Disorder with Anxiety and Depressed Mood	9400	50%	20040614
↓No Additional MEB/PEB Entries↓	Other x2	20040625
Combined: 20%	Combined: 60%

Derived from Veterans Affairs Rating Decision (VARD) dated 14 July 2004 (VARD closest to separation)
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ANALYSIS SUMMARY : IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.

Chronic LBP S /P Lumbar Fusion Condition . The CI has a well-documented history of LBP as evidenced by the numerous notes in the service treatment record . The CI was initially seen for an onset of acute LBP in 199 4 after squatting weights. In September 1996, the CI was involved in a minor motor vehicle accident ; however , the exam was focused on his cervical spine. A lumbar spine magnetic resonance imaging ( MRI ) exam noted posterior central and paracentral broad based disc protrusion L4-5 and L5-S1 . The CI was seen for constant back pain and right leg radiculopathy. A lumbar spine MRI showed right paracentral disc herniation L5-S1, right c entral paracentral disc protrusion at L4-5 which slightly indented the dural sac and which might affect the right L5 root sleeve. Plain spine films performed on the same date showed a pars defect (typically a congenital defect in the vertebral body) on the right at L5. The n eurologist noted that the CI had a normal motor and sensory exam. In February 2002, the CI was hospitalized for 3 days with the diagnosis of acute LBP and radiculopathy. The CI was evaluated by o rthopedics in April 2010 and was found to have full range-of-motion ( ROM ) . H owever , there was degenerative disc disease at L4-5 and L5-S1 with a pars defect at L5 bilaterally. The CI was placed on q uarters for 24 hours in May 2002. Due to intractable LBP, the CI underwent discography at L2-3, 2-4, 4-5 and L5-S1 in June 2002 that was consistent with discogenic pain. A CT scan post - discography on the same date confirmed the lumbar spine pathology. The CI underwent a lumbar spine fusion on 26 S eptember 2002. In January 2003, the CI complained that his back pain was worse than before surgery and he required narcotic medication for pain relief. The CI was given a temporary P4 Profile for LBP s/p lumbar fusion . The MEB n arrative s ummary (NARSUM) exam prepared approximately 8 months prior to separation documented that despite traditional therapy such as non-ste roidal anti-inflammatory drugs , physical therapy, transcutaneous electrical nerve stimulation unit and narcotic pain medications, the LBP continued. The MEB NARSUM physical exam findings are summarized in the chart below . The n on- m edical assessment performed in May 2003 noted that the CI’s medical condition limited his ability to fully perform his AFS duties. The CI was seen in the p ain clinic in June 2003 for chronic LBP which was constant stabbing pain in the low back right side with pain going down the right leg and both legs at night and intermittent numbness in the left leg. A third lumbar spine MRI demonstrated mildly bulging discs at L4-5 and L5-S1 partially effacing the inferior foraminal fat bilaterally at both levels . N o disc protrusion or nerve root impingement was seen. The VA Compensation and Pension (C&P) exam performed approximately 6 months after separation noted that the CI’s LBP with severe degenerative disease which required a fusion, had a significant impact on his occupation and daily activities. The VA C&P physical exam findings are summarized in the chart below . There was one ROM evaluation in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation .

DOS 20031214

Thoracolumbar ROM (In degrees)	MEB 8.10 Mo. Pre-Sep	VA C&P ~6.50 Mo. Post-Sep
Flexion (90 Normal)	-	50
Ext (0-30)		10
Combined (240)		150
Comment	mild discomfort pacing moving with difficulty; L4-S1 spinous pain to palpation; motor/sensory intact	Significant discomfort; Gait n or m a l; slightly tender throughout lumbar area; no discomfort increase or aggravation with repetitive motion; no neuro deficits

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The Board directs attention to its rating recommendation based on the above evidence. The VASRD “old Spine Rules” were in effect at the time of the CI’s disposition by the D isability E valuation S ystem. The PEB used these rules to rate the c hronic LBP condition, coded 5295 l umbosacral strain , and initially rated at 10% (with characteristic pain on motion) . The FPEB presumabl y used the same “old VASRD Spine Rules” and increased the rating to 20% . The Board notes that a lthough they did not change the VASRD code, verbiage contained on the FPEB’s f indings and r ecommendations document suggest s the FPEB may have utilized VASRD code 5293, i ntervertebral d isc s yndrome (also in effect at the time of separation) to arrive at the 20% rating level based on incapacitating episodes . If that was the case, it was reasonable that the result of the CI’s discogram suggests that his symptoms may have been caused primarily by an intervertebral disc syndrome. Additionally, the CI did not have the muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position required for the 20% rating under code 5295. The VA used the “n ew Spine Rules ” effective on 2 7 September 2003 and code d the CI’s LBP condition 5242 ( d egenerative arthritis of the s pine ) and rated it 20% based on a f orward flexion of the thoracolumbar spine of 50 degrees. The VA examination included a ROM measurement that supports th at 20% rating IAW the g eneral f ormula for r ating d iseases and i njuries of the s pine (greater than 30 degrees but not greater than 60 degrees) . The MEB NARSUM did not contain any documentation related to the motion of the lumbar spine and it is unclear if the C&P exam represent ed post-separation worsening of the CI’s condition. The Board adjudged that the C&P examination was the most probative exam as it was more proximate to separation (although accomplished after separation) and was the more complete exam when applying the ROM based new spine rules which were in effect at the time of separation. T he Board , IAW DoDI 6040.44, may not recommend a lower combined rating than that conferred by PEB and must utilize the rating guidelines in effect at the time of separation. The PEB granted a combined rating of 20% for the CI’s back pain condition and the most probative C&P exam also supports a rating of 20 %. The Board recognizes that code 5295 was not present in the VASRD at the time of separation; however, changing the code currently applied in th is case would be of no advantage to the CI . A fter due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of the c hronic LBP s/p l umbar f usion 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. In the matter of the c hronic LBP s/p l umbar f usion 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:

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UNFITTING CONDITION	VASRD CODE	RATING
Chronic L ow B ack P ain s/p Lumbar Fusion	52 95	2 0%
COMBINED	2 0%

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invalid font number 31502 T invalid font number 31502 he following documentary evidence was considered:
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invalid font number 31502 Exhibit A. DD Form 294, dated 20 invalid font number 31502 120911 invalid font number 31502 , w/atchs invalid font number 31502
Exhib invalid font number 31502 it B. Service Treatment Record invalid font number 31502
Exhibit C. Department of Veterans invalid font number 31502 ’ Affairs Treatment Record invalid font number 31502

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invalid font number 31502 XXXXXXXXXXXXXXXXXXXX invalid font number 31502 , DAF
President
Physical Disability Board of Review invalid font number 31502
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SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

Dear XXXXXXXXXXXXXXXXXXXX :

         Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2012-01647.

         After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate. Accordingly, the Board recommended no re-characterization or modification of your separation.

         I have carefully reviewed the evidence of record and the recommendation of the Board. I concur with that finding and their conclusion that re-characterization of your separation is not warranted. Accordingly, I accept their recommendation that your application be denied.

                                                               Sincerely,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

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AF | PDBR | CY2012 | PD2012 01647

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