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AF | PDBR | CY2013 | PD-2013-01739
Original file (PD-2013-01739.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXX     CASE: PD-2013-01739
BRANCH OF SERVICE: AIR FORCE     BOARD DATE: 20141105
SEPARATION DATE: 20041126


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSgt/E-5 (3A071/Information Management) medically separated for lumbar spine condition. The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards. She was issued a temporary L4 profile and referred for a Medical Evaluation Board (MEB). The condition, characterized as “low back pain (LBP) with multi-level herniated discs and right lower extremity (RLE) radiculopathy” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. No other conditions were submitted by the MEB. The Informal PEB (IPEB) adjudicated “chronic lower back pain with herniated nucleus pulposus and right lower extremity radiculopathy” as unfitting, rated at 10% citing criteria referencing Veterans Affairs Schedule for Rating Disabilities (VASRD) . The CI appealed to the Formal PEB (FPEB) which affirmed the IPEB finding and ratings.


CI CONTENTION: “Chronic low back pain please see medical records TMJ migraines back pain other service connected 0 comp or percentage.”


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 condition is addressed below; no 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 FPEB – Dated 20040727
 VA - (4 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Lower Back Pain With Herniated Nucleus Pulposus And Right Lower Extremity Radiculopathy. 5243 10% Lumbar Spine Intervertebral Disc syndrome L5-S1, Status Post Herniation At L2-S1 5243 20%
20050307
Other x 0 (Not in Scope)
 Other x 5 (Not in Scope)
Rating: 10%
 Combined: 40%
Derived from VA Rating Decision (VA RD ) dated 200 51230


ANALYSIS SUMMARY:

Chronic Lower Back Pain and Right Lower Extremity Radiculopathy Condition. The narrative summary notes that the CI had a gradual onset of LBP. Lumbar spine magnetic resonance imaging (MRI) performed on 21 March 2003 demonstrated multiple bulging discs in the lumbar spine (degenerative disc disease) which contacted the exiting spinal nerve roots bilaterally, greater on the right than the left. The CI underwent chiropractic treatments, which notes indicated provided temporary improvement with some symptom free days. The symptoms recurred and the CI was referred to pain management for epidural steroid injections (ESI), also with temporary improvement. At an orthopedic evaluation performed on 26 November 2003 the CI reported LBP with radiation to the right thigh, with tingling of the right foot, without weakness or other neurological symptoms and back pain was worse than the leg pain. The examination noted an abnormal spinal contour with a “list to the left side,” without tenderness to palpation (TTP) of the lumbar spine or sacroiliac joints. There was mild weakness of the hip and thigh muscles and the examiner noted motor exam was limited by “guarding due to pain.” The CI was able to heel and toe walk without difficulty. Lower extremity (LE) reflexes were normal with decreased sensation of the entire right LE (RLE) in a stocking distribution (not typical of a single spinal nerve root or non-radicular). To evaluate the RLE symptoms a repeat MRI was ordered, but there was no significant change noted from the earlier MRI. The orthopedic surgeon indicated that surgery was “not absolutely indicated, it would be elective,” and the CI declined further evaluation or surgery. Family Medicine notes from May to September 2004 indicated the CI reported her back pain “was moderately well improved” after another ESI, with daily muscle relaxant, anti-inflammatory medications and pain medications as needed. There were six prescribed periods of “quarters” of 1 to 2 days duration for the back condition within two years of separation but no incapacitating episodes or quarters were documented in the 12 months prior to separation.

At the MEB examination performed on 2 March 2004 (approximately 9 months prior to separation), the CI reported progressive chronic back pain. The MEB physical exam noted a normal gait. There was no TTP of the lumbar spine or sacroiliac joints and LE strength was normal. There was decreased sensation to light touch in the RLE in a “stocking” distribution. Reflexes were normal. Lumbar spine range-of-motion (ROM) was flexion 100 degrees (normal 90 degrees) extension of 10 to 15 degrees (normal 30 degrees) and all ROM was deceased due to pain. Straight leg raise testing was negative bilaterally. The examiner’s impression was a “painful right lower extremity radiculopathy, although no specific dermatomal symptoms.”

At the VA Compensation and Pension (C&P) spine examination performed on 7 March 2005 (approximately 3 months after separation), the CI reported her last significant LBP exacerbation with muscle spasm was in October 2004. (1 to 2 months prior to separation). The CI reported mild LBP aggravated by activities, without radiation or weakness. Self-treatment consisted of limiting aggravating activities, stretching, working out on the elliptical machine 3 to 5 times per week and walking one and a half miles. There was no list of medication in service treatment records (STRs) but the examiner noted use of opioid pain medication. The CI reported that she had decided not to work due to her back pain and the side effects of her medication. On examination the CI had a normal gait, with mild lumbar scoliosis. She was able to heel and toe walk. There was no TTP of the lumbar spine or muscle spasm present. Lumbar ROM was flexion of 50 degrees, extension of 20 degrees and combined ROM of 170 degrees and the CI was noted to be “guarding” with ROM. Lower extremity strength and sensation were normal, reflexes noted an absent right patellar reflex and ankle reflexes bilaterally. Sitting SLR was negative. Lumbar spinal X-ray images noted decreased disc space at L5-S1. The examiner noted intervertebral disc syndrome, “without residual lower extremity radiculopathy” and commented “No radiating pain, no root tension signs, no weakness, no sensory loss but reflex changes which can be from many different causes therefore a diagnosis of radiculopathy is not warranted.”

The Board directs attention to its rating recommendation based on the above evidence. The FPEB rated the back condition at 10% and while the VA’s rating was 20%, both coded 5243 (intervertebral disc syndrome). The Board considered the CI’s history of significant back pain with muscle spasm and radiation of pain with mild weakness and decreased sensation of the right lower leg. The CI’s MEB examination was more than 8 months prior to separation and review of notes in the STR indicates that it coincided with a period of chiropractic treatments noted to temporarily improve the CI’s symptoms, which did worsen after the MEB examination. There was no spasm or abnormal spinal contour noted at either the MEB or C&P examinations. However, notes in the STRs proximate to separation indicated daily use of a muscle relaxant medication and later evidence in record suggests episodes of muscle spasm continued, consistent with the lumbar spine abnormalities noted on MRI. Board members consensus was that the totality of evidence in record supports the 20% rating based upon VASRD spine rating guidelines in effect at the time of separation due to the ROM noted at the C&P examination and documented episodes of back pain with muscle spasm. The Board reviewed to see if a higher rating was achieved in accordance with VASRD spine ratings based upon incapacitating episodes defined as “. . . requires bed rest prescribed by a physician and treatment by a physician.” Although there were several periods of quarters within 2 years of separation, in the year prior to separation there were no incapacitating episodes documented in the available records. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the LBP condition, coded 5243.

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to lumbar radiculopathy. Notes in the STRs indicated that initially the CI had symptoms of radiating pain with sensory disturbances of the RLE, which decreased in frequency following treatment. During the MEB and C&P examinations there were no consistent findings of lumbar radiculopathy of either LE. The MEB examiner noted a “painful right radiculopathy” and C&P examiner indicated that overall, “a diagnosis of radiculopathy is not warranted.” Any radiating pain from the back condition is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates)…..” Therefore the critical decision is whether or not there was a significant LE motor or sensory deficit which would impact military occupation specific activities and there is no evidence in this case of any weakness or sensory abnormality that could be described as functionally impairing. The Board concluded therefore that no additional disability rating for peripheral nerve impairment could be 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 chronic LBP condition, the Board unanimously recommends a disability rating of 20%, coded 5243 IAW VASRD §4.71a. In the matter of the contended RLE radiculopathy 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
Chronic Low Back Pain 5243 20%
Right Lower Extremity Radiculopathy Not Unfitting
COMBINED 20%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130915, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record





                 
XXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAF/MRB
Dear XXXXXXXXXXXXXX:
         Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2013-01739.

         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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities. Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay.

         I have carefully reviewed the evidence of record and the recommendation of the Board. I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force. The office responsible for making the correction will inform you when your records have been changed.

                                                               Sincerely,






 XXXXXXXXXXXXXX
Director
Air Force Review Boards Agency
Attachments:
1. Directive
2. Record of Proceedings

cc:
SAF/MRBR

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