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AF | PDBR | CY2013 | PD-2013-00696
Original file (PD-2013-00696.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2013-00696
BRANCH OF SERVICE: Army  BOARD DATE: 20150123
SEPARATION DATE: 20011111


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (19D/Cavalry Scout) medically separated for chronic neck and lumbar pain. The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty. He was issued a permanent U3/L3 profile and referred for a Medical Evaluation Board (MEB). The chronic neck and lumbar pain conditions, characterized as “cervical spine pain and lumbar spine pain” and “mild degenerative disk disease (DDD), cervical spine,” were the only conditions forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB adjudicated “chronic neck pain,” and “chronic lumbar pain” as unfitting, rated 10% and 10% respectively, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “The issues that I would like to be addressed is the ratings for my cervical and lumbar spine condition, as well as depression which was noted on my exit physical exam but never addressed by the Army. I am rated at 20% for Degenerative Disc Disease of the Lumbar Spine, 20% for Degenerative Disc Disease of the Cervical Spine, and 30% for Depression – due to medical condition (neck & back). It is clearly noted that while I was on active duty, I suffered from depression as noted on standard form 93, standard form 88, standard form 507. Since my injury on that MIAI battle tank back in 1999 until my discharge on 11-11-2001 until this present day I still suffer a great deal of pain physically and mentally.”

His complete submission is at Exhibit A.


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 ratings for the unfitting chronic neck and lumbar pain conditions are addressed below; neither the depression nor any other additional conditions are within the DoDI 6040.44 defined purview of the Board. 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 Military Records.


 RATING COMPARISON :

Service IPEB – Dated 20010906
 VA - (4 Mo. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Neck Pain 5285-5299-5295 10% DDD of Cervical Spine 5293 10% 20020307
Chronic Lumbar Pain 5295 10% DDD of Lumbosacral Spine 5293 20% 20020307
Other x 0 (Not in Scope)
 Other x 3
Combined: 20%
 Combined: 30%
Derived from VA Rating Decision (VA RD ) dated 200 20319 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY: The 2001 VASRD coding and rating standards for the spine, which must be applied to the Board’s recommendation IAW DoDI 6040.44, differ significantly from the current §4.71 General Rating Formula for the Spine. The VA also applied the old spine rules initially, but incorporated the new spine rules in subsequent reviews.

Chronic Neck Pain Condition. The service treatment record (STR) documents that the CI sustained neck and back injuries when he fell off the rear deck of a tank on 31 August 1999. He fell approximately 6 to 8 feet and landed on the ground flat on his back. The 11 April 2000 cervical spine X-ray showed a probable chronic compressive injury of the 5th cervical (C5) vertebra with early osteoarthritic changes. A 28 March 2001 cervical spine magnetic resonance imaging (MRI) showed DDD at the C3-4 and C4-5 with mild bilateral neuroforaminal narrowing. The 12 June 2001 orthopedic surgery evaluation for the MEB recorded the CI had an old cervical spine injury from a fall off of a tank. It listed a normal physical exam with a normal gait, neurological exam, and reflexes. Neck range-of-motion (ROM) was full. Provocative diagnostic testing (Spurling’s [assesses cervical nerve root compression by a herniated disc]) was negative. The diagnoses were chronic neck pain and mild DDD with bulges. In the 25 July 2001 MEB narrative summary (NARSUM) prepared by orthopedic surgery, the CI recounted the history of a fall and subsequent posterior neck pain. The CI failed conservative therapy (anti-inflammatory medications and physical therapy) of the muscle strain and symptoms became progressively worse to 7/10 pain. The CI reported he was unable to perform his job-related duties secondary to pain and pain interfered with his sleep. Pain was exacerbated up to 10/10 by lying down for prolonged periods, prolonged standing, and physical activity (walking, bending, jumping, and load bearing). Physical exam showed no gross asymmetry or abnormality of the neck. The CI complained of pain at extremes of ROM. The neck ROM is summarized in the chart. Cervical pain was noted on axial spine compression (Spurling’s test) and resisted motion of the upper extremities. The neurological exam recorded normal strength (5/5) and intact light touch and reflexes. The diagnoses were cervical spine pain and mild DDD.

At the 13 March 2002 Compensation and Pension (C&P) exam, the CI complained of chronic neck pain. The CI reported the pain gave him significant impairment and was relieved with anti-inflammatory and sometimes narcotic medications. Physical exam showed upper extremity strength, sensation, and reflexes were intact. Provocative testing did not elicit signs of nerve compression. The neck ROM is summarized in the chart. The diagnosis was DDD of the cervical spine. The ROM evaluations which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Cervical ROM
(Degrees)
 Orthopedics ~ 5 Mo. Pre-Sep
 MEB ~ 4 Mo. Pre-Sep
 VA C&P ~ 4 Mo. Post-Sep
Flex (45 Normal)
 FROM FROM 30 (>15 < 30)
Combined (340)
 FROM FROM 150 ( < 170)
Comment
 Norma l Neuro and Gait Pain at extreme of ROM N one
§4.71a Rating
 0% 0% (10% 4.59) 20% (New spine rules)

The Board directed its attention to its rating recommendation based on the above evidence. A month prior to separation the PEB, rated the neck pain condition at 10% coded 5285-5299-5295 (vertebra, fracture of, residuals-rating by analogy-lumbosacral strain: with characteristic pain on motion). The PEB cited a mild C5 compression fracture by X-ray, disc bulging, DDD, full ROM with pain at extremes, no radiculopathy, and no spasm. The VARD dated 4 months after separation rated the neck pain condition at 10% coded 5293 (intervertebral disc syndrome: mild). The VARD cited DDD by X-ray, MRI and pain. The VA also used the ROM from the C&P exam. The Board notes that the two prior exams equally proximate to separation showed full ROM and were done by separate orthopedic surgeons. These exams are therefore assigned a higher probative value for rating purposes. 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 notes that the 2002 VASRD standards for the spine were in effect at the time of separation. On 11 April 2000, the cervical spine X-ray showed a probable chronic compressive injury of C5, the higher resolution on 28 March 2001 MRI did not show a compression fracture. The Board concluded the preponderance of evidence supported no higher than a 10% rating under the 5285 code. Under code 5299-5295, the pain on motion supported the 10% rating. There was no muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position to support the 20% rating. The Board next considered whether a higher rating was warranted under code 5293 used by the VA. While the cervical spine MRI showed DDD and mild bilateral neuroforaminal narrowing, the CI did not report radiating pain or recurring attacks. As exams were negative for signs of radiculopathy or objective neurologic findings, the preponderance of evidence supported no higher than a 10% rating under code 5293. The Board concluded that the preponderance of evidence did not support a rating higher than the 10% rating assigned by the PEB. After due deliberation, considering all 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 neck pain condition.

Chronic Lumbar Pain Condition. The STR documents that the CI sustained a back injury when he fell off a tank on 31 August 1999. The abdominal CT on 2 September 1999 showed no significant abnormality. The lumbar and thoracic spine X-rays on 17 September 1999 showed no vertebral body fracture or subluxation. A lumbar spine MRI on 28 March 2001 showed a L4-5 right paracentral disc protrusion. On 12 June 2001, an orthopedic surgery evaluation for the MEB recorded the CI had a 2-year history of back pain from a fall off of a tank in 1999. It listed a normal physical exam with a normal gait, neurological exam, and reflexes. The back ROM was full. Provocative diagnostic testing (straight leg raise test [assesses nerve root compression by a herniated disc by eliciting sciatic nerve pain with the leg between 30 and 70 degrees]) was negative. The diagnoses were chronic back pain and mild DDD with bulges. In the 25 July 2001 MEB NARSUM, the CI recounted the history of the fall and subsequent mid-lumbar pain. The CI failed conservative therapy of the presumed muscle strain. The symptoms became progressively worse and the CI reported he was unable to perform his job secondary to pain and pain interfered with his sleep. Pain was exacerbated up to 10/10 by prolonged lying, prolonged standing, and physical activity. Physical exam showed no gross asymmetry or abnormality of his back. The CI complained of pain at extremes of ROM. The spine ROM is summarized in the chart. Spine palpation showed no step-offs with T-2 tenderness to fairly firm palpation. The neurological exam recorded normal strength (5/5) and intact light touch and reflexes. Straight leg raise tests were negative. The diagnoses were lumbar spine pain and mild DDD. The CI was seen in the emergency room for back pain on 10 September 2001, 2 months prior to separation. The gait and ROM were noted to be normal.

At the 13 March 2002 C&P exam the CI complained of chronic back pain and light posterior leg pain. The CI reported the pain caused significant impairment and was relieved with anti-inflammatory and, sometimes, narcotic medications. The back physical exam elicited pain down the right leg with flexion to 45 degrees and extension to 10 degrees. Straight leg raise tests caused back pain on the left and back and posterior leg pain on the right. The spine ROM is summarized in the chart below. The diagnoses were DDD of the lumbosacral spine with some mild-to-moderate right leg radiculopathy. The CI also reported that he was seeking employment with a police department. The 10 April 2006 neurology H&P noted that he had worked as a deputy sheriff after separation (start date not recorded), but was no longer able to work, since December 2005, secondary to his back, neck and shoulder pain. The exam showed a normal ROM, gait, neurological exam, and absence of atrophy. The thoracolumbar ROM evaluations are summarized in the chart below.

Thoracolumbar ROM
(Degrees)
 Orthopedics ~ 5 Mo. Pre-Sep MEB ~ 4 Mo. Pre-Sep VA C&P ~ 4 Mo. Post-Sep
Flexion (90 Normal)
 FROM 70 (>60 < 85) 45 (>30 < 60)
Combined (240)
 FROM # 165 ( < 120)
Comment
 Norma l Neuro and Gait Pain at end of ROM R LE pain with flex/ext
§4.71a Rating
 0% 10% 20% (New spine rules)

The Board directed its attention to its rating recommendation based on the above evidence. The PEB rated the lumbar pain condition at 10% coded 5295 (lumbosacral strain: with characteristic pain on motion). The PEB cited disc bulging, DDD, functional ROM, pain, no neural impingement, no radiculopathy, and no spasm. The VARD rated the lumbar pain condition at 20% coded 5293 (intervertebral disc syndrome: moderate). The VARD cited DDD on MRI, pain limited ROM, and a positive right straight leg raise test. There was no spine pathology for consideration under codes 5285 (lumbar vertebra fracture), 5286 (spine ankylosis), or 5289 (lumbar spine ankylosis). The preponderance of evidence supported no higher than a 10% rating under code 5295. The pain on motion supported the 10% rating, but there was no muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position to support the 20% rating. The Board next considered whether a higher rating was warranted under code 5293 used by the VA. The lumbar spine MRI showed a L4-5 right para-central disc protrusion that touched both nerve roots and the CI did report recurring radiating pain. While exams were intermittently positive for signs of a right leg sensory radiculopathy, there was no evidence that motor weakness or sensory loss existed to any degree that could be described as functionally impairing. The Board also noted that the CI was able to work as a deputy sheriff after separation. The evidence supported no higher than a 10% rating under code 5293. The Board concluded that the preponderance of evidence did not support a rating higher than the 10% rating assigned by the PEB. After due deliberation, considering all the evidence and mindful of VASRD §4.3, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the lumbar 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. 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 neck pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the lumbar pain 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 re-characterization of the CI’s disability and separation determination.
The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130524, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                 
XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review


 SAMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXX , AR20150006404 (PD201300696)

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                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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