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AF | PDBR | CY2013 | PD-2013-02758
Original file (PD-2013-02758.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-02758
BRANCH OF SERVICE: ARMY  BOARD DATE: 20140826
SEPARATION DATE: 20071123


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (63B/Light Wheeled Vehicle Mechanic) medically separated for a low back condition. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The low back condition, characterized as “low back pain (LBP) secondary to L5/S1 spondylolisthesis, status post lumbar fusion L4-L5 and L5-S1”was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated “L4-5 and L5-S1 lumbar fusion for spondylolisthesis (with spina bifida occulta)”as unfitting and rated it at 0%. The CI made no appeals and was medically separated.


CI CONTENTION: “I have continued constant pain in lower back and legs due to injury. I also have limited range of motion and cannot do many things that I enjoy due to restrictions caused by my back injury.” 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 rating for the unfitting low back 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 IPEB – Dated 20070828
 VA - (One Mo. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
L4-5 and L5-S1 Lumbar Fusion for Spondylolisthesis 5241 0% Lumbar IVDS/Thoracic Spondylosis/Status Post Laminectomy, Lumbar Spine 5240-5243 20% 20071002
Others x 0 (Not in Scope)
 Other x 7 20071002
Combined: 0%
 Combined: 60%
Derived from VA Rating Decision (VA RD ) dated 200 71210 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Back Condition. The initial visit for LBP in the record is dated 14 October 2003 when the CI reported pain after a ruck march. He was next seen on 19 August 2004 when he reported LBP without trauma. A magnetic resonance imaging (MRI) on 13 September 2004 noted that he had a herniated disc at L4-5 and “slippage” of L5 on S1. He was evaluated in neurosurgery on 10 November 2004 and reported a year-long history of LBP. The neurological and range-of-motion (ROM) examinations were normal. He was also noted to have a congenital defect of the spine (spina bifida occulta.) When evaluated by a chiropractor 2 weeks later, the CI noted that the etiology might have been from (an injury in) jump school in March 2003 followed by a long road march. He subsequently underwent lumbar fusion. A follow-up MRI on 6 April 2005 noted good alignment and intact disc spaces. Flexion/extension studies showed no instability of the spine. The record then falls silent until a primary care evaluation on 30 April 2007. He reported pain radiating into his extremities and spasm. On examination, there was no spasm. The gait, stance, ROM and neurological examination were normal. He then completed a
12-mile ruck march with aggravation of the LBP. He was referred back to neurosurgery and subsequently was referred for an MEB. Per the narrative summary (NARSUM), an MRI on 24 May 2007 showed scar tissue at L4-5 and L5-S1 with the nerve roots at L5-S1 encased. However, he was seen in primary care on 5 June 2007 and noted to have a normal neurological examination and ROM. Spasm was absent. The NARSUM noted that he had an injection on 7 July 2007 without resolution of his pain.

The NARSUM was dated 30 July 2007. The CI reported that he had a bad landing on his fourth jump in Airborne School in March of 2003. He underwent lumbar fusion in March 2005 and did well with an L2 profile until he attended Air Assault School in 2007. Since then, he had noted re-aggravation of his LBP. On examination, he had no tenderness or spasm along the spinal muscles. The ROM was limited by pain and documented below (from a 30 July 2007 physical therapy evaluation.) Strength and reflexes were normal.

At the VA Compensation and Pension (C&P) exam performed 6 weeks prior to separation on 2 October 2007. The CI reported incapacitating episodes 30 times a year each of which lasted 30 days [sic] as well as no incapacitating episodes over the past year. Review of the clinical record does not show that the CI was sent home from work for LBP. He noted that he was unable to walk or stand for prolonged periods of time. On examination, he had a normal posture, but an antalgic (guarding from pain) gait secondary to the back. Neither spasm nor tenderness was present. The ROM is charted below and limited by pain. Repetition increased his symptoms, but did not result in further limitation in motion. An L5 sensory deficit was noted bilaterally. The reflexes were normal. The discussion of motor function was illegible. The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)		 MEB ~4 Mo. Pre-Sep VA C&P ~ 1.5 Mo. P re -Sep
Flexion (90 Normal) 60 35
Combined (240) 185 75
Comment Motion painful; able to sit and rise, stand, and walk without difficulty Limited by pain
§4.71a Rating 20 % 20 %

The Board directed attention to its rating recommendation based on the above evidence. The PEB used the code 5241 (spinal fusion) and rated the back condition at 0%. The VA coded the back 5240-5243 (ankylosing spondylitis and intervertebral disc syndrome) and rated the back at 20%. The Board noted that the ROM for both the MEB and VA examinations supports a 20% rating, but the criteria for a 40% rating are not met. The VA C&P history for incapacitation is self-contradictory; there is no evidence in the records reviewed that the CI was placed on bed rest (incapacitation) for his LBP. 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 back condition, rating the 5241 code utilized by the PEB. The Board also noted that the CI was rated 10% bilaterally for a radiculopathy. The Board considered if an unfitting neuropathy condition was present at separation. The VA C&P examiner documented the presence of a bilateral L5 radiculopathy at separation. However, several previous examinations noted a normal neurological examination. Regardless, whether present or not at separation, there is no evidence in the record that there was duty impairment from a neurological condition other than the back pain. The record does not support the presence of an unfitting radiculopathy at separation; accordingly, no ratable condition was present for adjudication. The Board concluded that this condition could not be recommended for additional disability rating.


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 back condition, the Board unanimously recommends a disability rating of 20%, coded 5241 IAW VASRD §4.71a. In the matter of the radiculopathy condition, the Board unanimously agrees that it cannot be recommended for an 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 his prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
L4-5 and L5-S1 Lumbar Fusion For Spondylolisthesis… 5241 20%
COMBINED 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131220, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record







                  XXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXX, AR20150006487 (PD201302758)


1. 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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation. This decision is final.

2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.

3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:




Encl                       XXXXXXXXXXXXXXX
                           Deputy Assistant Secretary of the Army
                           (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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