Chiari Malformation & Syringomyelia...NARSUM recvd!

Warrior644 · Sep 6, 2015

ColoradoRN said:
I have been resourcing this site for two months and have gained an enormous amount of knowledge from it. Thank you!
I would greatly appreciate any advice that can be given for my dilemma. I will try to make things as concise as possible.
My husband (USMC 1998-2002, 0351 & AD Army, 2005-present, 11B) was referred to IDES for a "neck condition". He completed 4 C&P exams and received NARSUM August 20, 2015. We consulted with Counsel at the Fort Carson JAG August 22, 2015.
A little history...he had an accident (referred to as "hard landing") in Feb 2006 in Airborne School. Not sure the exact details but there were issues with the parachute, he landed and his buttocks, hit his head and had LOC for approx. 35 minutes. He was subsequently transported to MACH where no fracture was seen (Later Dx as L1 60% vertebral compression fxt), however a CT Scan revealed enlarged lateral ventricles consistent with normal-pressure hydrocephalus. He was released from the MACH ED the same day, and continued to follow-up with PT from 2006-2007. During this time he was a Combatives Instructor and had near knock-outs where he was dazed and "saw stars" (according to C&P). He deployed to Iraq in 2008, Drill Sgt. 2010-2013, and Afghanistan 2013-2014.
In 2007 he began having low back pain that increased in severity. 2011 had L4-S1 spinal fusion. 2012 began having severe neck pain, L shoulder pain, numbness, tingling, etc. He was referred to MEB after 8 months PT and they said they could not work with him anymore due to his neck condition. He is also not a surgical candidate. In December 2014 Cervical MRI findings are consistent with Chiari Malformation as evidenced by low lying cerebellar tonsils and Syrinx" (3 mm), along with degenerative changes. Follow-up MRI to check the size of the syrinx for growth in June 2015, where it remains at 3mm.

The AWESOME C&P examiner/neurologist at Denver VA described his Syringomyelia as "Asymptomatic" and did not address the Chiari Malformation. During his MEB he had no EMG performed and she stated "without clinical evidence of radiculopathy" (despite his complaints of pain, numbness, and tingling in the bilateral upper and lower extremities and her tactile sensation finding of L thumb numbness) on his thoracolumbar and cervical ROM exams. NO Intervertebral Disk Syndrome (IVDS), despite both Lumbar and Cervical MRI findings of moderate-severe foramen narrowing at various levels, osteophyte complexes, and spinal stenosis. Her mTBI diagnosis was all negative despite subjective symptoms, and objective findings such as the Emergency report with LOC. His mental health result was negative for mTBI was negative in all facets.

When we went to JAG last week the lawyer said we could request IMR. We had feelings of anger that Radiculopathy will not be diagnosed for him. We wanted to have Chiari on the NARSUM. A Dr. called the next day and said that he added the Chiari and it now reads Chiari Malformation with Asymptomatic Syringomyelia. It has never been more apparent how much his Syringomyelia symptoms align with those already diagnosed such as headaches, shoulder impingement, sleep apnea, difficulty breathing, GU symptoms, limited ROM, etc, yet they are disregarded and coined "Asymptomatic". The lawyer stated that we could not appeal because Chiari/Syrinx is not an unfitting condition. Now we are planning to appeal based on MRI results for radiculopathy and I would really like to add IVDS.
I have written so much that I am starting to confuse myself! Our goal is to get greater than 30% DoD. The lawyer also stated that CRSC is probably not in our future. She says "take your blue card and enjoy all of the privileges that you will be awarded". She also maintains that anything greater than 30% DoD will be of no benefit to us and it is not worth the time of submitting appeals. She is very resistant to appeals and said that we could do that after he gets out.
If anyone has words of wisdom for us prior to Tuesday, please chime in. Any help will be greatly appreciated!

Welcome to the PEB Forum!

Wow! Hmm as based upon my experiences within the DoD IDES process, it continues to amazes (e.g. bothers) me of the "legal advice" received from some DoD IDES process trained legal council to include their seemingly lack of professionalism in the continued performance of their assigned legal duties! :confused:

To me with basis upon the information you provided, it seems that your husband is a future candidate for CRSC compensation to include potentially receiving at least a DoD - Army 30% proposed rating for military retirement disability compensation benefits as follows:

On the high side: A cervical 30% rating (ROM-based max. only) + a thoracolumbar 40% rating (ROM-based max. only) + a stand-alone separate radiculopathy 10% rating (for each different arm/leg/etc) = minimum 62% combined rating --> rounded down to a minimum 60% combined Army rating, or
On the low side: A cervical 10% rating (ROM-based min. only) + a thoracolumbar 10% rating (ROM-based min. only) + a stand-alone separate radiculopathy 10% rating (for each different arm/leg/etc) = minimum 27% combined rating --> rounded up to a minimum 30% combined Army rating

In my opinion, the bottom line is to implement your DoD IDES MEB legal right for the opportunity to submit an IMR and/or a MEB Soldier's appeal now while still in the MEB phase because their is "no later" opportunity upon your husband's completion of the MEB process!

As such, if an unfavorable MEB appeal determination is founded, at least your MEB appeal disagreement shall be officially annotated within your DoD IDES case file at this point in time. Moreover, if your husband's DoD IDES case proceeds to the PEB phase, then your husband shall have another IDES appeal's opportunity via the Formal PEB (FPEB) hearing.

To that extent with certainty as based upon my experiences within the DoD IDES appeals process, if you elect for a FPEB hearing, the Informal PEB (IPEB) shall definitely review at a minimum your MEB documentation in order to potentially reference "any" previous non-annotation of medical condition concern(s) on your part in support of their PEB findings for sure!

With that all said, please never default acceptance to any injustices while in the DoD IDES MEB/PEB process; fight then continue to fight some more until receipt of your desired outcomes as supportable via all available medical evidence and/or medical documentation!

Hopefully, other PEB Forum members shall provide their insights, comments, feedback and/or experiences additionally too! Take care, continue to get well, and most importantly enjoy life! :cool:

Thus, I quite often comment that "possessing well-informed knowledge is truly a powerful equalizer."

Best Wishes!

ColoradoRN · Sep 6, 2015

Thanks Warrior! I am truly *star struck*

Any thoughts specifically regarding the Chiari/Syrinx being deemed "unfit" and deserving of a DoD rating?

The MEB Soldier's appeal you mentioned, is there an example of that somewhere on the forum? It seems as though I have seen it once before... :mad:

As a healthcare provider, I am able to utilize my knowledge, education, and experience to ensure others are well-informed, specifically, the MEB/PEB. THAT is my equalizer!

Warrior644 · Sep 7, 2015

ColoradoRN said:
Thanks Warrior! I am truly *star struck*
Any thoughts specifically regarding the Chiari/Syrinx being deemed "unfit" and deserving of a DoD rating?

The MEB Soldier's appeal you mentioned, is there an example of that somewhere on the forum? It seems as though I have seen it once before...

As a healthcare provider, I am able to utilize my knowledge, education, and experience to ensure others are well-informed, specifically, the MEB/PEB. THAT is my equalizer!

No worries; you are welcome!

Hmm, I am not familiar with the Chiari/Syrinx medical condition to include its symptomologies for any potential military service connected disability rating by the DoVA D-RAS at this point unfortunately.

Of most importance upon referral and acceptance into the DoD IDES MEB/PEB process, the medical conditions and/or medical impairments need to impact the ability of a military service member to perform his/her military duties appropriate to their office, grade, rank, or rating.

Indeed, the available medical evidence and/or medical documentation for the Chiari/Syrinx medical condition needs to show that the advances in modern medicine to include the best efforts of your husband were not effective enough to be returned to a military full-duty status.

Moreover, the MTF MEB Convening Authority will bring together a board of medical officers who will decide whether or not to refer your husband's IDES case to the PEB. If yes, then the assigned PEBLO will forward the completed MEB case file to the PEB. If not, then your husband will be returned to duty. If returned to duty with a P3 or P4 profile, then your husband must undergo an administrative review on whether he is worldwide deployable under field conditions for his medical condition(s). This review includes consideration of Military Occupational Specialty (MOS) reclassification.

To that extent, the PEB will convene an Informal PEB (IPEB) to initially adjudicate your husband's IDES case. The IPEB will review all medical and non-medical evidence contained in your husband's IDES case file. If the IPEB determines that your husband is fit, they will issue findings that will be forwarded to his assigned PEBLO. If your husband is found unfit, then each of his unfitting medical impairments will be identified and his IDES case file will be sent to the designated DoVA DES Rating Activity Site (D-RAS).

Upon receipt by the DoVA D-RAS, they shall use the VA Schedule for Rating Disabilities (VASRD) to assign a disability rating to each of the PEB-referred and VA claimed medical conditions that they determine were incurred or aggravated during a period of qualified military service. Afterwards, they will report the results in their Rating Decision which will be included in your husband's IDES case file and returned to the PEB.

As such, the PEB will then issue findings that identify each unfitting condition and include information on those medical impairments rated by the DoVA D-RAS. The PEB determines whether or not your husband will be retired or separated as a result of his medical conditions. These findings and the VA Rating Decision will be sent to the assigned PEBLO who has a requirement to deliver the findings within three working days of receipt and then counsel your husband on his election of options.

In reference to a sample or an example MEB Soldier's appeal, I would suggest that you use the "search" function within the PEB Forum website to potentially locate any available documentation. Otherwise, hopefully, others shall potentially provide assistance as outlined in your specific inquiry. I definitely concur, your equalizer is awesome!

Take care! :cool:

Thus, I quite often comment that "possessing well-informed knowledge is truly a powerful equalizer."

Best Wishes!

ColoradoRN · Sep 9, 2015

My case in point...this cracks me up! This was lawyers response to the appeal letter I sent last night...
I am on AT until 21 Sep. If they don't grant your appeal, or only grant it
in part, you can still go to a formal board. You really only need to get to
30% to get medical retirement because you'll like have a full offset with VA
so getting more on the Army won't necessarily put in any more money in your
pocket, except for possible CRSC.

gsfowler · Sep 10, 2015

Quick question(s) When your husband receoved his C&P evaluation, how did they address neuropathy? Typically they use a pin-prick method, which is a participative exercise? Has your husband has an EMG exam completed?

I too was med-boarded for cervical spine issues (referring condition) and from the onset, I was counseled by the VA MEB liason that getting greater than 30% from the military is very difficult, as the rating is primarily based upon range of motion and that it is measured with a goiniometer which can be very loosely interpreted by the provider who performs the exam.

Because of this, I chose too look deeply at every other condition that I had, to see if any others were unfitting for service to meet the 30% retirement (for me I had a visual field defect due to traumatie brain injury) that was rated at 30%. The Army fought very hard to not award me on this condition.

What the 30% did provide for me was ZERO dollars, and Tricare for Retirees (Tricare for Life in my circimstance, since I received Medicare Part A & Part B from SSDI). The medical benefits are basically useless for me, since I can utilize the VA healthcare network, and the Tricare for my wife (Prime) sucks.

You may want to do the financial calculations to see what may be better off for you and your family. If you husband gets separated at 0%, he will get his severance pay, and have to pay nothing to the VA, if he gets 10%, than 10% of his C&P will be withheld until the severance is paid back, if he gets 20% than 20% gets witheld until the severance is paid back. (think of it as a 0% interest loan against future C&P benefits).

gsfowler · Sep 10, 2015

Here is a AF case proceeding that may help provide clarity on getting the Chari Malformation unfitting. http://boards.law.af.mil/AF/PDBR/CY2012/PD2012-00535.pdf

scoutCC · Sep 11, 2015

I'm sure the lawyer's response cracked you up because it is a little cynical and suggests the end result is more important than things being right. The exact opposite of Warrior's normal line. Its important to remember that going to the FPEB represents a risk. There are cases where the FPEB looks more closely at things and disagrees and lowers the ratings. Sometimes accepting the outcome you want is more important than fighting for the right and just answer.

When doing the value calculation, as gsfowler suggests, don't forget to consider CRSC. Since this was rooted in a airborne jump it should be eligible for simulating war.

I will also note that a doctor is far better qualified to discuss a diagnosis than you, as a lay person (even as a healthcare provider, I imagine they will consider your statements lay evidence). They are however less well qualified to discuss if a symptom exists or not. It is perfectly reasonable for you and your husband, and coworkers, commanders, etc., to discuss symptoms. Due to the amount of time spent observing, lay evidence easily be taken more seriously than a short C&P examination when it comes to deciding if a condition is asymptomatic or not.

ColoradoRN · Sep 15, 2015

5. No change in the NARSUM or DA 3947 appears necessary.

The referenced memorandum asks that the Service Member (SM) be found to fall below retention standards for the diagnosis of “Radiculopathy”, Chiari Malformation/Syringomyelia” and Left Shoulder Impingement Syndrome”. The SM also wished to elaborate on perceived deficiencies with the VA examination. Accompanying statement from SM was reviewed.

Non-concur with listing the diagnosis of Cervical radiculopathy as a condition failing ARS. The VA C&P did not provide a diagnosis for the unclaimed condition of radiculopathy because there were no objective findings to support the diagnosis. A review of the AHLTA notes does not find evidence of objective findings consistent with a cervical radiculopathy. The consult for the 12 Mar 2015 examination by Neurology services was not for an EMG but to evaluate your multiple musculoskeletal complaints, a small syrinx in lower cervical cord and degenerative changes in the cervical spine. The examination findings did not indicate that an upper extremity EMG was indicated. Further, findings on radiographs and MRIs are not necessarily diagnoses and must be supported by objective physical findings (Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain; Jensen, New England Journal of Medicine 1994; Overuse of Magnetic Resonance Imaging, Emery, et al, JAMA Internal Medicine 2013). In your case, there is no evidence of a radiculopathy, therefore, the claimed condition is not present and cannot fail ARS.

Non-concur with listing the diagnosis of Chiari Malformation/Syringomyelia as a condition failing ARS. The reasons this condition does not fail ARS were well documented in the Independent Medical Review/Impartial Physician Review performed by Dr. Maisel on 1 Sept 2015. Please refer to that document for all findings. The preponderance of evidence indicates that this condition has not limited or interfered with duty performance.

gsfowler · Sep 15, 2015

The IMR is anything but impartial. It is conducted by a physician that typically works in the same MTF that your husbands MEB physician does. They review the paperwork that is in your husbands file.

In my own personal case, there were multiple medical notes and opinions that were not reviewed by the IMR, as they were not in AHLTA (As far as the IMR is concerned, if the not is not in AHLTA, it does not exist) the IMR only looks at what is in the computer and nothing else. They do not conduct an exam of your husband, and they do not really have an independent opinion.

Fortunately for me, I had reviewed the NARSUM and was able to gather each of the medical notes/opinions to provide to my IMR physician (by scanning and emailing to him) to get him to reluctanly change the diagnosis that the MEB physician had made. Although this was a percieved triumph, the NARSUM actually came back as a lesser rating and I was retalited against by having my privledge to drive an automobile removed due to the diagnosis that I WAS NOT rated for.

My PEBLO saw the irony of the errors and had my file sent to a QA team to get it re-rated, it took nearly six months in limbo, but it did come back with the condition as failing. In another twist (retaliation) the MEB doctor listed failing condition as congenital (another attempt to block medical retirement) however I had overwhelming medical evidence to show that the condition was directly related to a blow to my head and the subsequent TBI that I had suffered.

When it was all said and done, the EPTS had to get tossed out, because that I had served more than eight years on active duty and there was no evidence in my medical file that condition had ever existed.

From this point, I accepted the findings and had my file sent to the VA for the rating process, my PEBLO made sure that al of my memorandums for the IMR and QA team were on the top of the file so that the rater would see them to make the correct deceision. It took nearly two years to get the file rated (due to backlog) and the net result was 100% P&T, the Army gave me a 40% rating (10% cervical spine after a neck fracture and two surgeries, based on ROM, would not accept the VA EMG as evidence for radiculopathy or neuralgia) and 30% for a visual field defect ( I had rock solid evidence that could not be disputed by a VA neuroopthamologist), allthough the Army optometrists first tried to deny it existed, then they would test me monthly to rule out (or in in my opinion) malingering.

Warrior644 · Sep 15, 2015

ColoradoRN said:
5. No change in the NARSUM or DA 3947 appears necessary.

The referenced memorandum asks that the Service Member (SM) be found to fall below retention standards for the diagnosis of “Radiculopathy”, Chiari Malformation/Syringomyelia” and Left Shoulder Impingement Syndrome”. The SM also wished to elaborate on perceived deficiencies with the VA examination. Accompanying statement from SM was reviewed.

Non-concur with listing the diagnosis of Cervical radiculopathy as a condition failing ARS. The VA C&P did not provide a diagnosis for the unclaimed condition of radiculopathy because there were no objective findings to support the diagnosis. A review of the AHLTA notes does not find evidence of objective findings consistent with a cervical radiculopathy. The consult for the 12 Mar 2015 examination by Neurology services was not for an EMG but to evaluate your multiple musculoskeletal complaints, a small syrinx in lower cervical cord and degenerative changes in the cervical spine. The examination findings did not indicate that an upper extremity EMG was indicated. Further, findings on radiographs and MRIs are not necessarily diagnoses and must be supported by objective physical findings (Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain; Jensen, New England Journal of Medicine 1994; Overuse of Magnetic Resonance Imaging, Emery, et al, JAMA Internal Medicine 2013). In your case, there is no evidence of a radiculopathy, therefore, the claimed condition is not present and cannot fail ARS.

Non-concur with listing the diagnosis of Chiari Malformation/Syringomyelia as a condition failing ARS. The reasons this condition does not fail ARS were well documented in the Independent Medical Review/Impartial Physician Review performed by Dr. Maisel on 1 Sept 2015. Please refer to that document for all findings. The preponderance of evidence indicates that this condition has not limited or interfered with duty performance.

At this point in time, sorry to hear the unfavorable results from your husband's MEB Soldier's appeal!

Albeit, remember that all is not lost in your quest to have aforementioned medical impairments ultimately determined PEB-referred "unfit for duty" since additional DoD IDES appeal opportunities exist while in the PEB phase if at least one medical condition is officially determined to be "medically unacceptable" within the IDES MEB phase.

Thus, I quite often comment that "possessing well-informed knowledge is truly a powerful equalizer."

Best Wishes!

ColoradoRN · Sep 30, 2015

Ratings are in! Why, oh why did I ever doubt the system? Drum roll... :rolleyes:

100% VA
30% DOD

If anyone is interested in the breakdown, let me know! I will still post them later today. I had to separate myself from the board over the past two weeks because it had consumed the better part of me. The file went up for ratings on Thursday and the PEBLO called Monday afternoon with the news.

Now it is just on to CRSC... :mad:

Warrior644 · Sep 30, 2015

ColoradoRN said:
Ratings are in! Why, oh why did I ever doubt the system? Drum roll...

100% VA
30% DOD

If anyone is interested in the breakdown, let me know! I will still post them later today. I had to separate myself from the board over the past two weeks because it had consumed the better part of me. The file went up for ratings on Thursday and the PEBLO called Monday afternoon with the news.

Now it is just on to CRSC...

Wow! A couple of days turnaround for VA proposed ratings! This is awesome news; congratulations!

Thus, I quite often comment that "possessing well-informed knowledge is truly a powerful equalizer."

Best Wishes!

LMH · Mar 31, 2017

Hello,
I know the post is a couple of years old. But I was curious about what you filed (regarding chiari) with the VA? I have a chiari malformation and had a chiari decompression surgery while in the Navy. In my first filing with VA, I listed chiari malformation, and they rated me 0% for a scar. I'm trying again with that & would be happy for any tips. Did you list all the residuals separately? Thanks in advance!

apple808 · Jul 18, 2021

gsfowler said:
Here is a AF case proceeding that may help provide clarity on getting the Chari Malformation unfitting. http://boards.law.af.mil/AF/PDBR/CY2012/PD2012-00535.pdf

This link doesn't work is there another way to get this information?

apple808 · Jul 19, 2021

LMH said:
Hello,
I know the post is a couple of years old. But I was curious about what you filed (regarding chiari) with the VA? I have a chiari malformation and had a chiari decompression surgery while in the Navy. In my first filing with VA, I listed chiari malformation, and they rated me 0% for a scar. I'm trying again with that & would be happy for any tips. Did you list all the residuals separately? Thanks in advance!

Hello, I saw your post and is going through the same thing did you ever get any answers for your chiari?

Chiari Malformation & Syringomyelia...NARSUM recvd!

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