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AF | PDBR | CY2014 | PD-2014-03788

Original file (PD-2014-03788.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX CASE: PD-2014-03788
BRANCH OF SERVICE: ARMY BOARD DATE: 20150407

SEPARATION DATE: 20020901

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E- 3 ( W ater Treatment Specialist ) medically separated for a neck condition. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards . He was issued a permanent U 3 pr ofile and r eferred for a M edical Evaluation Board (MEB). The “ c ervical degenerative disk disease ( DDD ) with C7 radiculitis and right-sided C 6-C7 herniated nucleus pulposus ” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501 . The MEB also identified and forwarded one other condition ( mild carpal tunnel syndrome [ CTS ] ) as meeting retention standards. The Informal PEB adjudicated “cervical degenerative disk disease with C7 radiculitis and right-sided C6-C7 herniated nucleus pulposus” as unfitting, rated 20%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CTS condition was determined to be not unfitting . The CI made no appeals and was medically separated .

CI CONTENTION: “Degenerative Disc Disease ... Please consider all conditions.” 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 cervical spine condition is addressed below. The requested carpal tunnel condition, which was determined to be not unfitting by the PEB, is likewise addressed. No additional conditions are within the DoDI 6040.44 defined purview of the Board. Any condition or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON :

IPEB – Dated 20020723	VA* (4 Mo. Pre -Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
Cervical DDD	5295 8699-8611	20%	DDD Cervical Spine with Left Upper Extremity Radiculopathy	5010-5293	20%	20020507
Mild CTS	Not Unfitting
Other x 0 (Not In Scope)	Other x 3
RATING: 20%	RATING: 20%

* Derived from VA Rating Decision (VA RD ) dated 200 20830 (most proximate to date of separation [ DOS ] ) .

ANALYSIS SUMMARY:

Cervical Spine Condition with Subsumed Radiculopathy. The service treatment record (STR) documented the onset of this condition with an injury in October 2001 (~11 months prior to separation). The CI fell during training impacting his left shoulder, neck, and head. He experienced an immediate onset of neck and left shoulder pain with left upper extremity (LUE [non-dominant]) radiation and sensory symptoms (transiently bilateral). Initial cervical X-rays demonstrated degenerative changes suggestive of DDD, but no traumatic findings. The pain and radicular symptoms persisted and magnetic resonance imaging (MRI) confirmed bi-level (C5-7) bulging discs with left-sided nerve encroachment at C5/6 (a shoulder MRI was normal). Electrodiagnostic (EMG) testing identified some distal LUE nerve impairment (“borderline left median neuropathy”) but no cervical nerve dysfunction. Surgery was offered and declined, and conservative measures (included spinal injections) did not achieve adequate pain relief. There were STR comments for both grossly normal and non-specifically decreased cervical range-of-motion (ROM), but no ROM measurements other than below. Although intermittent complaints of LUE subjective weakness and sensory disturbance persisted, the majority of STR entries documented normal objective neurological findings (including grip strength). Two entries (both in January 2002, 8 months prior to separation) documented mild LUE motor (strength) deficits, one of these noting distal sensory impairment. There was no STR evidence for periods of incapacitation.

A VA Compensation and Pension examination conducted on 7 May 2002 (4 months prior to separation) and documented persistent neck pain (rated 7-8/10) radiating down the LUE (posterior) into the hand, with hand paresthesias (radial/palmar). Physical limitations were not elaborated, and no functional consequences of the neurological symptoms were noted. The VA physical exam documented “full cervical [ROM],” but painful motion; and, made no mention of spasm or tenderness. The neurological exam recorded normal LUE strength (5/5), but some triceps and trapezial atrophy.

The narrative summary (NARSUM), dated 31 May 2002 (3 months prior to separation), documented persistent left-sided neck and LUE pain (rated 8/10, “moderate and constant”); there was no mention of sensory symptoms, but “some clumsiness in the [LUE].” As with the VA exam, no physical limitations or functional consequences were elaborated. The NARSUM physical exam documented rigid guarding of neck movements and cervical tenderness with measured ROM of 30 degrees flexion (normal 45) and combined ROM of 120 degrees (normal 340). The neurological findings were “diffuse decreased motor strength most obvious on the left at the triceps and at the dorsal interosseous muscle of the hand ... decreased sensation in the C7 dermatome on the left side” with normal reflexes. Specifically noted was the absence of any atrophy (counter to VA finding). The commander’s performance statement documented lifting and load-bearing limitations (general cervical vs. LUE neurological impairment could not be differentiated), but noted that the CI’s “duty performance is satisfactory” outside the physical constraints of his profile. The U3 profile specified only cervical DDD, and all specified limitations were intrinsic to that condition.

The Board directed attention to its rating recommendation based on the above evidence. The PEB’s 20% rating was coded 5295-8699-8611, e.g., cervical strain rated analogously as “mild” nerve impairment (middle radicular group). The VA’s 20% rating, using code 5293 (intervertebral disc syndrome), also explicitly subsumed the LUE radiculopathy, although it provided a single rating under a spine code as opposed to the PEB’s single rating under a nerve code. The 2002 VASRD rating standards for the cervical spine, which must be applied to the Board’s recommendation IAW DoDI 6040.44, differed significantly from the current §4.71a general rating formula for the spine. The 5295 component of the PEB code was in fact written for lumbar strain, and the criteria did not lend themselves to cervical rating. Given the absence of ankylosis, the only two applicable spine codes under the VASRD in effect were the following:

5290 Spine, limitation of motion of, cervical

Severe ...................................................................................................................................... 30
Moderate ................................................................................................................................. 20

Slight ........................................................................................................................................ 10

5293 Intervertebral disc syndrome:

Severe; recurring attacks, with intermittent relief .................................................................. 40
Moderate; recurring attacks .................................................................................................... 20
Mild .......................................................................................................................................... 10
Postoperative, cured ................................................................................................................. 0

Given the PEB’s coding choice, members first deliberated whether the primary unfitting impairment was neurologic; whether it was intrinsic to the cervical pain and limitations from DDD; or, whether there were separately unfitting cervical and peripheral nerve conditions. The fact that the functional impairment from the radiculopathy could not be extricated from that of CTS (discussed below), and that CTS was determined by the PEB to be not unfitting, suggested that the PEB code was intended only as an analogous rating standard (not intended to convey fitness implications). The evidence indicated that the only functionally significant neurologic impairment was some loss of strength and perhaps coordination (NARSUM “clumsiness”) of the non-dominant arm; this was not detected by the majority of examiners, and there was no evidence that manual dexterity was affected. The intermittently documented sensory deficits of the non-dominant arm and hand did not have significant functional implications for MOS requirements. Neither the commander’s statement nor the profile specified any limitations specifically attributable to LUE impairment. Any specific LUE or manual functional limitations could only be inferred from physical findings, since none were documented in the available evidence. Members thus agreed that there was inadequate justification to conclude that there was unfitting neurologic impairment as a basis for a primary or separate disability rating.

Having so decided, the Board turned to deliberation of the appropriate code and rating recommendation for the unfitting cervical DDD condition. The VA’s assessment of moderate disability under 5293 was reasonable, and the performance evidence did not support a recommendation premised on severe disability. The evidence likewise supported a conclusion that the ROM limitation was fairly characterized as moderate, and the intermittently normal ROM (as documented in the STR and by the VA examiner) did not support a recommendation premised on severe limitation. After due deliberation, considering all of 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 rating of the cervical spine condition under any available code.

Contended Carpal Tunnel Syndrome. The diagnosis of CTS was entertained during the evaluation of the cervical radicular symptoms, and the EMG demonstrated that a distal neuropathy (borderline median nerve neuropathy, not specific to CTS) made a significant contribution to the LUE neurologic symptoms and findings as elaborated above. The VA examiner opined that there was not a distinct separate diagnosis of CTS, invoking the non-specific EMG findings, and treated the LUE neurological condition solely as a cervical radiculopathy. The NARSUM examiner differentiated a “C7 radiculitis” from CTS, and opined that “his cervical disease is likely contributing to his mild carpal tunnel symptoms.” The examiner further stated, “I would continue to manage the [CTS] with a wrist brace and this should not enter into any disability assessment for the purposes of this [MEB].” As noted above, the CTS condition was forwarded as medically acceptable, was not profiled, and was not specifically implicated by the commander.

The Board’s main charge with respect to this condition is an assessment of the fairness of the PEB’s determination that it was not unfitting. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The functional impact of CTS is integrated with that of the cervical radiculopathy; and, the overall LUE neurologic impairment has already been established as not unfitting. After 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 fitness determination for the CTS 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 cervical spine condition with subsumed radiculopathy and IAW VASRD §4.71a (in effect), the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended carpal tunnel syndrome, the Board unanimously recommends no change from the PEB determination as not unfitting. 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 20140605, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXXX AR20150007447 (PD201403788)

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                                                  XXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR

( ) DVA

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AF | PDBR | CY2014 | PD-2014-03788

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