Citation Nr: 1533322	
Decision Date: 08/05/15    Archive Date: 08/11/15

DOCKET NO.  09-24 838	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Roanoke, Virginia


THE ISSUES

1.  Entitlement to an increased initial evaluation for cognitive impairment and other residuals of TBI not otherwise classified, rated as 40 percent disabling for the period from October 23, 2008, to January 17, 2011, and as 70 percent disabling from January 18, 2011. 

2.  Entitlement to an increased initial evaluation for PTSD, rated as 50 percent disabling for the period from October 23, 2008, to June 14, 2010, and as 70 percent disabling from June 15, 2010. 

3.  Entitlement to an increased initial evaluation for slow speech due to TBI, rated as 30 percent disabling for the period from May 1, 2007, to May 26, 2009, and as noncompensable from May 27, 2009. 

4.  Entitlement to an increased initial evaluation for intervertebral disc syndrome (IVDS) without degenerative joint disease (DJD) of the lumbar spine, rated as 10 percent disabling for the period from May 1, 2007, to January 17, 2011, and as 20 percent disabling from January 18, 2011. 

5.  Entitlement to an initial evaluation in excess of 20 percent for sciatic nerve deficiency of the left leg due to IVDS of the lumbar spine.

6.  Entitlement to an increased initial evaluation for posttraumatic stress disorder (PTSD) and cognitive disorder due to traumatic brain injury (TBI), rated as 50 percent disabling from May 1, 2007, to October 22, 2008.

7.  Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) during the period prior to October 3, 2011.
 

REPRESENTATION

Appellant represented by:	Veterans of Foreign Wars of the United States


WITNESSES AT HEARING ON APPEAL

Appellant and his wife


ATTORNEY FOR THE BOARD

D. Van Wambeke, Counsel


INTRODUCTION

The Veteran served on active duty from August 1979 to December 1979, from January 1983 to January 1987, from January 1991 to August 1991, from January 1992 to March 1992, from January 1997 to October 1997, and from September 2001 to April 2007.  His awards and decorations include the Purple Heart.

These matters come to the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia.  

In pertinent part, the November 2007 rating decision granted service connection for the following: PTSD and cognitive disorder due to TBI with a 50 percent rating; slow speech due to TBI with a 30 percent rating; sciatic nerve deficiency of the left leg due to IVDS of the lumbar spine with a 10 percent rating; and IVDS without DJD of the lumbar spine with a 10 percent rating.  The effective date of these awards was May 1, 2007, the date following the Veteran's discharge from active duty service.  

In April 2009, the Veteran requested reevaluation of his residuals of TBI under the criteria that had been established in October 2008.  In an August 2009 rating decision, the Roanoke RO granted a separate 40 percent rating for cognitive impairment and other residuals of TBI not otherwise classified, effective October 23, 2008, the date on which the regulations pertaining to TBI were amended.  The RO also decreased the 30 percent rating assigned for slow speech due to TBI to zero percent (or noncompensable), effective May 27, 2009.  The Veteran thereafter perfected an appeal.  

In May 2010, a hearing was held at the Board's Central Office in Washington, D.C. before the undersigned Veterans Law Judge.  A transcript of that hearing has been associated with the record.  The Board remanded the claims numbered one through six as listed on the title page in December 2010.  

The Veteran filed a claim for entitlement to a TDIU in July 2011.  In a February 2012 rating decision, the Appeals Management Center (AMC) granted that claim effective October 3, 2011.  The AMC also increased the rating assigned for PTSD to 70 percent, effective June 15, 2010; the rating assigned to cognitive impairment and other residuals of TBI not otherwise classified to 70 percent, effective January 18, 2011; and the rating assigned to IVDS without DJD of the lumbar spine to 20 percent, effective January 18, 2011.  The Board also notes that the AMC granted entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C.A. § 1114 (s) and 38 C.F.R. § 3.350(i), effective October 3, 2011.  

Despite the increased ratings granted by the AMC for the service-connected PTSD, cognitive impairment and other residuals of TBI not otherwise classified, and IVDS without DJD of the lumbar spine, the Veteran's appeal concerning these claims remains before the Board.  Cf. AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed a notice of disagreement as to an RO decision assigning a particular rating, a subsequent decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). 

The Board remanded the claims as listed on the title page in October 2012.  As noted then, since the Veteran has repeatedly contended that he became too disabled to work on July 12, 2011, the issue of entitlement to a TDIU prior to October 3, 2011, remains on appeal.  The claims were remanded by the Board again in October 2014.  

The current record before the Board consists entirely of electronic files known as Virtual VA and the Veterans Benefits Management System (VBMS).

The Board referred the issues of entitlement to service connection for a headache disorder due to TBI and entitlement to service connection for dizziness due to TBI in December 2010, October 2012, and October 2014.  These issues have still not been adjudicated by the Agency of Original Jurisdiction (AOJ).  Since the Board does not have jurisdiction over them, they are again referred to the AOJ for appropriate action.  38 C.F.R. § 19.9(b) (4).  This is especially important given that the Schedule of Ratings for Neurological Conditions and Convulsive Disorders, Residuals of TBI, stipulates that any subjective residual of TBI with a distinct diagnosis that may be evaluated under another diagnostic code should be separately evaluated.  See 38 C.F.R. § 4.124(a), Diagnostic Code 8045.  

In March 2013, the Veteran submitted a statement in which he questions how his retroactive pay under the Combat-Related Special Compensation (CRSC) payments was calculated.  The Board notes that it appears the Veteran may also be seeking clarification as to why his combined 100 percent rating was effective in June 2010 rather than May 2007.  To the extent this statement is in references to retroactive pay under CRSC, that issue is again referred to the AOJ for appropriate action.  To the extent that the statement is in reference to the Veteran's belief that he should have a combined 100 percent schedular rating going back to the date on which service connection for his disabilities was established, that question is part and parcel of the issues currently before the Board.  More simply, if the Board determines that ratings in excess of those currently assigned prior to June 22, 2010, when the Veteran's combined schedular evaluation rose to 100 percent, are warranted, that may result in a combined rating in excess of the 90 percent combined rating the Veteran was in receipt of between May 1, 2007, and June 21, 2010.  

The issues of entitlement to an increased initial evaluation for PTSD and cognitive disorder due to TBI, rated as 50 percent disabling from May 1, 2007, to October 22, 2008; and entitlement to a TDIU during the period prior to October 3, 2011, are addressed in the REMAND portion of the decision below and are again REMANDED to the AOJ.


FINDINGS OF FACT

1.  The Veteran's symptoms associated with cognitive impairment and other residuals of TBI not otherwise classified, do not equate to higher than a level 2 at any time between October 23, 2008, and January 17, 2011; or to higher than a level 3 at any time as of January 18, 2011. 

2.  As of October 23, 2008, the Veteran's PTSD was manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; but was not manifested by total social impairment.  

3.  The Veteran's slow speech due to TBI was not manifested by one-half or more loss of tongue at any time between May 1, 2007, and May 26, 2009, or marked speech impairment at any time as of May 27, 2009. 

4.  Prior to January 18, 2011, the Veteran's lumbar spine disability was not so severe as to cause symptoms manifested by forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; a combined range of motion of the thoracolumbar spine not greater than 120 degrees; muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; or IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months.

5.  Between January 18, 2011, and November 1, 2011, the Veteran's lumbar spine disability was not so severe as to result in forward flexion of the thoracolumbar spine limited to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine; or IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months.  

6.  The Veteran was only able to achieve 20 degrees of flexion in his thoracolumbar spine at the time of a November 1, 2011, VA examination report.  

7.  The Veteran's lumbar spine disability has not been manifested by unfavorable ankylosis of the entire thoracolumbar spine, or IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months, as of November 1, 2011.

8.  The Veteran was diagnosed with right L5 radiculopathy on January 18, 2011.

9.  The examiner who conducted the November 1, 2011, VA examination provided an opinion that the Veteran's erectile dysfunction was secondary to his lumbar IVDS.  

10.  The medical and lay evidence dated throughout the appellate period does not support a finding that the Veteran's sciatic nerve deficiency of the left leg is moderately severe.  


CONCLUSIONS OF LAW

1.  The criteria for an initial rating in excess of 40 percent for cognitive impairment and other residuals of TBI not otherwise classified have not been met between October 23, 2008, and January 17, 2011.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2014).  

2.  The criteria for an initial rating in excess of 70 percent for cognitive impairment and other residuals of TBI not otherwise classified have not been met as of January 18, 2011.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2014).  

3.  The criteria for an initial rating of 70 percent, and not higher, for PTSD have been met as of October 23, 2008.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2014). 

4.  The criteria for an initial rating in excess of 30 percent for slow speech due to TBI have not been met between May 1, 2007, and May 26, 2009.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.114, Diagnostic Code 7202; 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2014).  

5.  The criteria for an initial compensable rating for slow speech due to TBI have not been met as of May 27, 2009.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.114, Diagnostic Code 7202; 38 C.F.R. § 4.124a, Diagnostic Code 8045 (2014).  

6.  The criteria for an initial rating in excess of 10 percent for IVDS without DJD of the lumbar spine have not been met prior to January 18, 2011.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2014).

7.  The criteria for an initial rating in excess of 20 percent for IVDS without DJD of the lumbar spine have not been met between January 18, 2011, and November 1, 2011.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2014).

8.  The criteria for an initial rating of 40 percent, and not higher, have been met for IVDS without DJD of the lumbar spine as of November 1, 2011.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2014).

9.  The criteria for an initial separate evaluation for right L5 radiculopathy have been met as of January 18, 2011.  38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2014).

10.  The criteria for an initial separate evaluation for erectile dysfunction have been met as of November 1, 2011.  38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 4.115b, Diagnostic Code 7522 (2014).

11.  The criteria for an initial evaluation in excess of 20 percent for sciatic nerve deficiency of the left leg due to IVDS of the lumbar spine have not been met.  38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.124a, Diagnostic Code 8520 (2014).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Duties to Notify and Assist

Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence necessary to substantiate the claim and the division of responsibilities in obtaining evidence.  See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006).  The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim.  Dingess v. Nicholson, 19 Vet. App. 473 (2006). 

In this case, the Veteran is disagreeing with the ratings assigned after service connection has been granted and initial disability ratings and effective dates have been assigned.  Thus the service connection claims have been more than substantiated, they have been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled.  Dingess, 19 Vet. App. at 490; Dunlap v. Nicholson, 21 Vet. App. 112 (2007).  

VA has obtained service treatment records; assisted the Veteran in obtaining evidence, to include private treatment records and records from the Social Security Administration (SSA); afforded the Veteran appropriate examinations to determine the severity of his disability, although he refused to report to the most recently-scheduled examinations; and afforded the Veteran the opportunity to give testimony before the Board.  All known and available records relevant to the issues on appeal being adjudicated in this decision have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. 

There was also substantial compliance with the Board's October 2012 and October 2014 remand instructions as they pertained to the claims being adjudicated in this decision, since additional VA treatment records were obtained; records from SSA were associated with the record; the RO made an attempt to obtain additional private treatment records from Dr. H.S.; Dr. D. at Georgetown University Hospital; and Sibley Memorial Hospital, though the Veteran did not provide a response to this attempt; the RO obtained outstanding treatment records from Walter Reed Army Medical Center (Walter Reed) and the National Naval Medical Center; the RO scheduled the Veteran for VA examinations to address the current severity of his PTSD, TBI, and lumbar spine and associated neurological disability, although the Veteran failed to report; and the RO sent the Veteran a letter giving him the opportunity to withdraw his appeal concerning any claim for which he seeks a higher schedular rating effective June 22, 2010, or later, when his combined schedular rating became 100 percent; with explanation that the Veteran will not be entitled to additional pay for any disability whose schedular rating is increased effective June 22, 2010, or later, to include the service-connected cognitive impairment and other residuals of TBI not otherwise classified, and the IVDS without DJD of the lumbar spine.  See D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999); see also letters dated November 2012 and October 2014.  

All known and available records relevant to the issues being adjudicated on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise.  Since VA has substantially complied with the notice and assistance requirements, the Veteran is not prejudiced by a decision on the claims being adjudicated at this time.

Increased Ratings - Procedural History, Assertions and Legal Criteria

Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities.  38 U.S.C.A. § 1155; 38 C.F.R. Part 4.  Separate rating codes identify various disabilities.  38 C.F.R. Part 4.  In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records.  See generally 38 C.F.R. §§ 4.1, 4.2.  Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating; otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7. 

Where the rating appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings."  See Fenderson v. West, 12 Vet. App. 119 (1999).

When evaluating disabilities of the musculoskeletal system, an evaluation of the extent of disability present also includes consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment, and the effect of pain on the functional abilities.  38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-06 (1995).  In other words, when rated for limitation of motion, a higher rating may be assigned if there is additional limitation of motion from pain or limited motion on repeated use of the joint.  A finding of functional loss due to pain must be "supported by adequate pathology and evidenced by the visible behavior of the claimant."  38 C.F.R. § 4.40. 

The Veteran contends that he is entitled to increased initial ratings for the disabilities being adjudicated in this decision.  The Board will lay out his general contentions prior to discussing the distinct procedural histories involved for each claim, the arguments specific to those disabilities, and before discussing the medical evidence associated with each disability.  At this juncture, the Board notes that the Veteran has received a substantial amount of regular medical care given the nature of his disabilities, and that the medical evidence in this case is voluminous.  The Board has reviewed the evidence in its entirety, but will not be discussing all of it with specificity.  See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007) (the Board is presumed to have considered all evidence presented in the record; it is not required to specifically discuss every piece of evidence).

In his December 2008 VA Form 9, the Veteran generally reported that his physical pain and mental health are severely tasked at work daily; that his TBI has affected his judgment and he frequently minimizes his pain and symptoms when seeking treatment; that he has medical appointments at VA facilities and Walter Reed on a weekly basis; and that his current state of health keeps him from working at his former capacity.  

A.  Increased initial evaluation for cognitive impairment and other residuals of TBI not otherwise classified, rated as 40 percent disabling for the period from October 23, 2008, to January 17, 2011, and as 70 percent disabling from January 18, 2011

Service connection was originally established for PTSD and cognitive disorder due to TBI in the November 2007 rating decision that is the subject of this appeal.  These disabilities were subsequently separated in an August 2009 rating decision, which established a separate rating for cognitive impairment and other residuals of TBI not otherwise classified pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8045.  A 40 percent rating was assigned effective October 23, 2008, the date on which the regulations were amended.  See August 2009 rating decision.  The rating was subsequently increased to 70 percent effective January 18, 2011.  See February 2012 rating decision.  

The Board notes at this juncture that the Veteran is also separately rated for slow speech due to TBI; status post facial burn with loss of eyebrow hair and metal fragments in head with residual scars; mild paralysis of the ocular nerve, left eye, due to TBI; trichiasis, right lower lid with keratoconjuctivitis, right eye and inactive chorioretinits, left eye with scotomata bilaterally; post tympanoplasty, right ear with residual scar; tinnitus; taste disturbance due to TBI; and decreased sensation of the musculocutaneous nerve, left forearm, due to TBI.  Only the slow speech due to TBI is also on appeal.  

The Veteran reports the following symptoms in his attempt to obtain higher initial ratings: memory loss; cognitive disorders; inability to concentrate; poor reading capability; frequent irritation; sudden angry outbursts; depression; low motivation; feelings of numbness; reduced executive functions; vestibular balance problems; blurred vision; aggression at work; poor sleep; and disturbing dreams.  He reports daily reminders about his injury while working on the Joint Improvised Explosive Device (IED) Defeat Organization, and feeling anxiety and stress at work; indicates that he is unable to sleep more than two hours at a time due to nightmares; that he has trouble getting along with his spouse at times and just shuts down; that he had several encounters at work where he was ready to become violent when challenged by other workers; that he cannot concentrate very long on things and avoids group activity and closeness; that he gets overwhelmed easily; and that he cannot handle math problems in his head and has a tough time with them on paper.  See December 2008 VA Form 9.  

In an April 2009 TBI signs and symptoms questionnaire that was provided to him by VA, the Veteran reported the following pertinent symptomatology: behavioral changes; mood changes; irritability/depression/anxiety; difficulty speaking/slurred speech; fatigue; insomnia; change in sleep patterns; weakness/poor coordination; numbness and tingling; confusion/memory problems/difficulty thinking; loss in problem solving abilities; and sensitivity to light or noise.  The Veteran also noted that his disabilities had stabilized.  

In a November 2009 statement in support of claim, the Veteran reports that he is less competent than prior to the blast injury, but high functioning with great effort; that reading is difficult and he has to read things several times to himself; that math presents a challenge but he has been coached by the VA poly-trauma team on how to compensate; and that to mitigate any financial risk, his wife handles financial affairs, though he has never been responsible for the family finances.  

Diagnostic Code 8045 in effect since October 23, 2008, states that there are three main areas of dysfunction that may result from TBIs and have profound effects on functioning: cognitive (which is common in varying degrees after TBI), emotional/behavioral, and physical.  Each of these areas of dysfunction may require evaluation.  38 C.F.R. § 4.124a, Diagnostic Code 8045 (2014).  

Cognitive impairment is defined as decreased memory, concentration, attention, and executive functions of the brain.  Executive functions are goal setting, speed of information processing, planning, organizing, prioritizing, self-monitoring, problem solving, judgment, decision making, spontaneity, and flexibility in changing actions when they are not productive.  Not all of these brain functions may be affected in a given individual with cognitive impairment, and some functions may be affected more severely than others.  In a given individual, symptoms may fluctuate in severity from day to day.  Cognitive impairment is to be evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified."  Id.  

Subjective symptoms may be the only residual of a TBI or may be associated with cognitive impairment or other areas of dysfunction.  Evaluate subjective symptoms that are residuals of a TBI, whether or not they are part of cognitive impairment, under the subjective symptoms facet in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified."  However, separately evaluate any residual with a distinct diagnosis that may be evaluated under another diagnostic code, such as migraine headache or Meniere's disease, even if that diagnosis is based on subjective symptoms, rather than under the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table.  Id.  

Evaluate emotional/behavioral dysfunction under § 4.130 (Schedule of ratings-mental disorders) when there is a diagnosis of a mental disorder.  When there is no diagnosis of a mental disorder, evaluate emotional/behavioral symptoms under the criteria in the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified."  Id.  

Evaluate physical (including neurological) dysfunction based on the following list, under an appropriate diagnostic code: motor and sensory dysfunction, including pain, of the extremities and face; visual impairment; hearing loss and tinnitus; loss of sense of smell and taste; seizures; gait, coordination, and balance problems; speech and other communication difficulties, including aphasia and related disorders, and dysarthria; neurogenic bladder; neurogenic bowel; cranial nerve dysfunctions; autonomic nerve dysfunctions; and endocrine dysfunctions.  Id.  

The current version of Diagnostic Code 8045 stipulates that the preceding list of types of physical dysfunction does not encompass all possible residuals of a TBI.  For residuals not listed here that are reported on an examination, evaluate under the most appropriate diagnostic code.  Evaluate each condition separately, as long as the same signs and symptoms are not used to support more than one evaluation, and combine under § 4.25 the evaluations for each separately rated condition.  The evaluation assigned based on the "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" table will be considered the evaluation for a single condition for purposes of combining with other disability evaluations.  Id.  

The current version of Diagnostic Code 8045 also stipulates that the need for SMC for such problems as loss of use of an extremity, certain sensory impairments, erectile dysfunction, the need for aid and attendance (including for protection from hazards or dangers incident to the daily environment due to cognitive impairment), being housebound, etc., must be considered.  Id.  As noted in the Introduction, entitlement to SMC pursuant to 38 U.S.C.A. § 1114 (s) and 38 C.F.R. § 3.350(i), was granted to the Veteran in a February 2012 rating decision issued by the AMC.  

The current version of Diagnostic Code 8045 also states that the table titled 'Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified' contains 10 important facets of a TBI related to cognitive impairment and subjective symptoms.  It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, and labeled "total."  However, not every facet has every level of severity.  The Consciousness facet, for example, does not provide for an impairment level other than "total," since any level of impaired consciousness would be totally disabling.  A 100-percent evaluation is to be assigned if "total" is the level of evaluation for one or more facets.  If no facet is evaluated as "total," the overall percentage evaluation based on the level of the highest facet is to be assigned as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent.  The regulation provides the following example: assign a 70 percent evaluation if 3 is the highest level of evaluation for any facet.  Id.  

There are five notes that accompany the current version of Diagnostic Code 8045.

Note (1): There may be an overlap of manifestations of conditions evaluated under the table titled "Evaluation Of Cognitive Impairment And Other Residuals Of TBI Not Otherwise Classified" with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code.  In such cases, do not assign more than one evaluation based on the same manifestations.  If the manifestations of two or more conditions cannot be clearly separated, assign a single evaluation under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions.  However, if the manifestations are clearly separable, assign a separate evaluation for each condition.

Note (2): Symptoms listed as examples at certain evaluation levels in the table are only examples and are not symptoms that must be present in order to assign a particular evaluation.

Note (3): "Instrumental activities of daily living" refers to activities other than self-care that are needed for independent living, such as meal preparation, doing housework and other chores, shopping, traveling, doing laundry, being responsible for one's own medications, and using a telephone.  These activities are distinguished from "Activities of daily living," which refers to basic self-care and includes bathing or showering, dressing, eating, getting in or out of bed or a chair, and using the toilet.

Note (4): The terms "mild," "moderate," and "severe" TBI, which may appear in medical records, refer to a classification of TBI made at, or close to, the time of injury rather than to the current level of functioning.  This classification does not affect the rating assigned under Diagnostic Code 8045.

Note (5): A Veteran whose residuals of TBI are rated under a version of § 4.124a, diagnostic code 8045, in effect before October 23, 2008, may request review under diagnostic code 8045, irrespective of whether his or her disability has worsened since the last review.  VA will review that veteran's disability rating to determine whether the veteran may be entitled to a higher disability rating under diagnostic code 8045.  A request for review pursuant to this note will be treated as a claim for an increased rating for purposes of determining the effective date of an increased rating awarded as a result of such review; however, in no case will the award be effective before October 23, 2008.  For the purposes of determining the effective date of an increased rating awarded as a result of such review, VA will apply 38 CFR 3.114, if applicable.

B.  Increased initial evaluation for PTSD, rated as 50 percent disabling for the period from October 23, 2008, to June 14, 2010, and as 70 percent disabling from June 15, 2010

Service connection was originally established for PTSD and cognitive disorder due to TBI in the November 2007 rating decision that is the subject of this appeal.  A 50 percent disability rating was assigned pursuant to Diagnostic Code 8045 in conjunction with 38 C.F.R. § 4.130, Diagnostic Code 9411.  These disabilities were subsequently separated in an August 2009 rating decision, which established a separate rating for PTSD.  The 50 percent rating was continued.  See August 2009 rating decision.  A 70 percent rating was subsequently assigned effective June 15, 2010.  See February 2012 rating decision.  

The Veteran reports the following symptoms in his attempt to obtain higher initial ratings: memory loss; inability to concentrate; frequent irritation; sudden angry outbursts; depression; low motivation; feelings of numbness; aggression at work; poor sleep; and disturbing dreams.  He reports daily reminders about his injury while working on the Joint IED Defeat Organization, and feeling anxiety and stress at work; indicates that he is unable to sleep more than two hours at a time due to nightmares; that he has trouble getting along with his spouse at times and just shuts down; that he had several encounters at work where he was ready to become violent when challenged by other workers; that he cannot concentrate very long on things and avoids group activity and closeness; and that he gets overwhelmed easily.  See December 2008 VA Form 9.  

In a November 2009 statement in support of claim, the Veteran reports that PTSD has impacted his personal and professional life, but he is being treated by VA for these issues and they are well under control.  

The Veteran testified in May 2010 that he had the following problems associated with PTSD: inability to sleep more than two hours at a time; trouble getting back to sleep; having dreams about the blast injury; reliving part of the blast injury every night; waking up from scary dreams with his heart racing; anxiety; numbness; less socially outgoing; avoidance of large crowds, to include at his children's' sport functions; impaired concentration and staying on task; getting overwhelmed easily; difficulty in handling math; a heightened sense of awareness and alertness resulting in a need to move rather than stay in one spot/hyperarousal; feelings of tension; road rage; hypervigilance/ritual perimeter checks; being set off by loud noises and seeing plumes of smoke; and suspiciousness.  The Veteran described two instances where he exhibited poor impulse control, the first while driving in Shenandoah with a car of teenagers, including his son, and trying to run a guy in another car off the road while the children were attempting to get him to calm down; and the second while shopping at Tyson's Corner when he took off chasing another car and left one of his son's friends standing on the sidewalk.  The Veteran's wife testified that the Veteran used to be very calm and mild mannered prior to the blast injury and that even their children have to work hard to get him to calm down now.  She also testified that he wakes up about three to four times a night and is unable to get back to sleep and that he checks doors every time he goes by.  At the time of his May 2010 hearing, the Veteran was employed as part of an IED task force, and he testified that none of his doctors were happy that he was working, especially given the environment of working with IED issues.  He reported that he was able to put his PTSD symptomatology aside in order to work, although he noted having some minor confrontations with people in the work environment, but had learned how to remove himself from those situations so he does not get fired.  The Veteran did report one physical confrontation at work in the parking lot, but noted that he was coming to the aid of a co-worker.  

In a June 2013 email, the Veteran reported that a VA call center took his request to withdraw a claim for aid and attendance because he could not risk the stress of his rating being reviewed and subject to reduction, as that process would elevate his risk of suicide.  

Pursuant to the General Rating Formula for Mental Disorders, a 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.  38 C.F.R. § 4.130, Diagnostic Code 9411 (2014). 

A 70 percent evaluation contemplates occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activity; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances and inability to establish and maintain effective relationships.  Id. 

Lastly, a 100 percent evaluation is warranted where there is total occupational and social impairment, due to symptoms such as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or name.  Id. 

The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating."  Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002).  In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment.  Id. at 443. 

When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission.  38 C.F.R. § 4.126(a).  The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination.  Id.   When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment.  38 C.F.R. § 4.126(b). 

A Global Assessment of Functioning (GAF) rating is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness.  Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994) (DSM-IV).

A GAF score generally reflects an examiner's finding as to the Veteran's functioning score on that day and, like an examiner's assessment of the severity of a condition, is not dispositive.  Rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned.  See 38 C.F.R. § 4.126(a) (2014). 

C.  Increased initial evaluation for slow speech due to TBI, rated as 30 percent disabling for the period from May 1, 2007, to May 26, 2009, and as noncompensable from May 27, 2009

Service connection for slow speech due to TBI was granted in the November 2008 rating decision that is the subject of this appeal.  A 30 percent disability rating was assigned pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8045, and 38 C.F.R. § 4.114, Diagnostic Code 7202, effective May 1, 2007.  The rating was decreased to zero percent effective May 27, 2009, in an August 2009 rating decision.  

The Veteran asserts that he is entitled to higher initial ratings because his speech is slower, especially when he is under stress; that he is unable to find the right words to use; that he has trouble with word association; and that he stutters a lot when stressed.  He asserts that slow speech makes it hard for him to perform his job on the engagement team for strategic communications; that he is unable to conduct long briefings or meetings due to slow speech pattern and poor word association; that he cannot confirm to the need at work to brief visitors; that his stuttering causes him to avoid public groups; that he cannot perform his job at the same level as he did in service due to slow speech and cognitive issues; and that he has trouble talking to large groups on official business or at meetings.  See December 2008 VA Form 9.  

During the Veteran's May 2010 hearing, his representative noted on the record that his speech pattern was a little slow and that it was not because of an accent.  The Veteran testified that he sees a speech pathologist on a fairly frequent basis and that his speech is one of the things he works hardest on for rehabilitation.  He also testified that he was used to public speaking and being able to articulate and explain things well, but now it is hard and it is hard to find the right words and associate words correctly.  The Veteran's wife testified that she had seen not only slowness in his speech, but slurring of words.  

The rating criteria for Diagnostic Code 8045 were discussed in detail above.  Diagnostic Code 7202 provides the criteria for tongue, loss of whole or part.  A 30 percent rating is warranted for marked speech impairment; a 60 percent rating is warranted for one-half or more tongue loss; and a 100 percent rating is warranted for an inability to communicate by speech.  

D.  Increased initial evaluation for IVDS without DJD of the lumbar spine, rated as 10 percent disabling for the period from May 1, 2007, to January 17, 2011, and as 20 percent disabling from January 18, 2011

Service connection for IVDS without DJD of the lumbar spine was granted in the November 2007 rating decision that is the subject of this appeal.  A 10 percent rating was assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5243, effective May 1, 2007.  In a February 2012 rating decision, the rating was increased to 20 percent effective January 18, 2011.  

In support of his claim for initial increased ratings, the Veteran contends that he has constant lower back pain and severe lower back pain in the L5 area.  He reports that multiple CT scans and examinations confirm that there is a protruding disc and the L5 vertebrate is canted 30 degrees.  The Veteran reports that medication creates drowsy conditions and affects his work; that he is unable to drive for more than one hour at a time due to back pain; and that he cannot stand on his feet for more than one hour at work due to back pain.  See December 2008 VA Form 9.  

In May 2010, the Veteran testified that his back pain has gotten worse each year since the in-service injury.  He reported that he was in a regular pain management clinic; was getting lumbar epidural steroid injections on both sides of his spine; and that he has to have someone drive him to those procedures and he has to leave work for them.  He reported that during range of motion testing on VA examination, he bent down to touch his toes because he knew it was only going to be painful for a couple of seconds, but that range of motion is painful for him.  The Veteran also noted that he was getting physical and recreation therapy, which is another block of time away from work.  He testified that he also had pain in his right leg in addition to the service-connected left leg and that he cannot lift very heavy things without a lot of back pain.  

In a July 2011 statement to his congressman, the Veteran reported that he had to stop work on July 12, 2011, due to complications with his back and loss of function in his right leg; that the VA hospital put him on medical leave until September 5, 2011; that he had been approved as a candidate for back surgery at Bethesda Medical Center in mid-August; and that he can only walk with the use of a cane.  

Disabilities of the spine (other than IVDS when evaluated on the basis of incapacitating episodes) are to be rated under the General Rating Formula for Diseases and Injuries of the Spine.  38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243.  These criteria are to be applied irrespective of whether there are symptoms such as pain (whether or not it radiates), stiffness, or aching in the affected area of the spine, and they "are meant to encompass and take into account the presence of pain, stiffness, or aching, which are generally present when there is a disability of the spine."  68 Fed. Reg. 51, 454 (Aug. 27, 2003).  Any associated objective neurologic abnormalities including, but not limited to, bowel or bladder impairment, are to be rated separately from orthopedic manifestations under an appropriate diagnostic code.  38 C.F.R. § 4.71a, Note (1).

In pertinent part, the General Rating Formula for Diseases and Injuries of the Spine provides a 10 percent rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height.  A 20 percent rating is provided for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.  38 C.F.R. § 4.71a.

Ratings in excess of 20 percent are provided for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine (40 percent); for unfavorable ankylosis of the entire thoracolumbar spine (50 percent); and for unfavorable ankylosis of entire spine (100 percent).  Id.  Ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure.  See Lewis v. Derwinski, 3 Vet. App. 259 (1992). 

38 C.F.R. § 4.71a, Note (2) provides that for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees.  See also Plate V, 38 C.F.R. § 4.71a.

Under the criteria governing disabilities of the lumbar spine, IVDS is to be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes.  This formula provides a 10 percent rating for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a rating of 20 percent for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent rating for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months.  An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician.  See 38 C.F.R. § 4.71a, Note (1).

E.  Initial evaluation in excess of 20 percent for sciatic nerve deficiency of the left leg due to IVDS of the lumbar spine

Service connection for sciatic nerve deficiency of the left leg due to IVDS of the lumbar spine was granted in the November 2007 rating decision that is the subject of this appeal.  A 20 percent rating was assigned pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8520, effective May 1, 2007.

The Veteran asserts that he is entitled to an initial increased rating because he has severe pain shooting down his left leg, normally from the left buttocks side to the top of the left foot.  The left foot feels like it is burning at times.  He also reports severe lower back pain in the L5 area and that multiple CT scans and examinations confirm that the sciatic nerve is the cause of the pain.  The Veteran asserts that medication creates drowsy conditions and affects his work; that he finds it hard to sit for more than 30 minutes at work due to numbness in his legs; and that his left leg feels weaker and he is unable to walk at a normal pace.  See December 2008 VA Form 9.  In a November 2009 statement in support of claim, the Veteran reports that he has severe sciatic nerve pain in his left side.  

The Veteran testified in May 2010 that his left leg pain was like a shot of electricity; that he was on his feet a lot at work and could not take a lot of pain medication; that it was hard to drive; and that it limits a lot of things he used to like to do.  The Veteran also testified that he had left leg numbness, that he had difficulty coordinating the use of his left leg, that he had trouble going up stairs/something steep; and that he has a limp.  The Veteran's wife testified to seeing him limp, dragging his leg behind him and grabbing things for support, and stumbling.  She reported that his legs will "flop" like a fish, which happens at least two to three times a day, causing the Veteran to grab his legs in pain.  

Diagnostic Code 8520 provides the rating criteria for impairment of the sciatic nerve.  Disability ratings of 10 percent, 20 percent and 40 percent are assigned for incomplete paralysis which is mild, moderate or moderately severe in degree, respectively.  A 60 percent rating is warranted for severe incomplete paralysis with marked muscle atrophy.  Complete paralysis of the sciatic nerve, which is rated as 80 percent disabling, contemplates foot dangling and dropping, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. 

The words "mild," "moderate," "moderately severe, "and "marked" are not defined in the Rating Schedule or in the regulations during this time period.  As such, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just."  38 C.F.R. § 4.6.

Medical Evidence

A May 2007 record from Walter Reed documents that the Veteran presented due to recent worsening of his radiating pain.  It was noted that he responded to Neurontin very well, and that he was mostly pain free for several months taking 1200mg/day (though would note some discomfort towards the end of the dosing schedule that would be helped by taking the next pill).  Recently, however, he had had a return of the severe pain, which is the same as described before (from the SI joint radiating down to the mid-calf).  He noted that this had affected his gait, though he was unsure if this is due to pain or weakness.  No other symptoms to include bowel/bladder complaints or numbness.  Physical examination revealed no sensory exam abnormalities and the Veteran was intact to pin prick.  Motor examination revealed strength was normal 5/5, throughout, no drift, normal tone; normal bulk, no tremor.  Normal, intact, spontaneous gait was reported and reflexes were normal 2+ and symmetrical throughout, including bilateral medial hamstring.  The Veteran's toes were down going, bilaterally.  The assessment was radiculopathy. 

An electromyography (EMG) was conducted in June 2007.  The conclusion was this is a normal electrodiagnostic study; there is no evidence of a lumbosacral radiculopathy; there is no evidence of a generalized peripheral neuropathy.  Clinically, the Veteran did have symptoms of an L5 radiculopathy that symptomatically improves with exercise.  It was noted that he was unable to have an MRI.  It was recommended that he continue with conservative treatment of exercises, stretching, and analgesic medications as needed.

The Veteran was seen at Walter Reed in July 2007 for follow up of radicular-type pain down his leg.  It was noted that he was doing well and had self-tapered Neurontin down to 1200mg per day and had been able to handle his current pain level except those times when he is required to sit for long periods such as in the car.  The Veteran continued to not have any weakness and denies any new symptoms.  No sensory abnormalities were noted on physical examination and the Veteran was intact to pin prick.  Motor examination revealed that strength was normal 5/5 throughout, without drift or tremor and with normal tone and bulk.  Gait was reported as normal, intact and spontaneous.  Reflexes were normal 2+ and symmetrical throughout, including the bilateral medial hamstring.  The Veteran's toes were down going bilaterally.  The assessment was radiculopathy.  It was noted the Veteran continued to have mild symptoms consistent with radiculopathy though these are being controlled with Neurontin.  It was also noted that EMG was normal, though this would be expected with mild nerve root compression.  

An August 2007 VA neurology outpatient consult note documents that the Veteran reported chronic back pain with radicular symptoms since 2000.  He indicated he had been on Neurontin started by a neurologist at Walter Reed, which controlled his symptoms.  Motor examination was normal.  Sensory examination revealed the Veteran was grossly intact to light touch and that pinprick was slightly decreased in the left leg throughout (states is 90% compared to 100% in the right leg); proprioception and vibration were intact in all four extremities.  Reflexes were normal.  The Veteran had good heel-knee-shin and there was no exaggerated rebound, position drift, or dysmetria/intention tremor.  Stance was normal based and gait and toe, heel and tandem gait were normal.  The assessment was chronic back pain with radicular symptoms; possible ankylosing spondylitis.  

A September 2007 VA rheumatology consult note documents the Veteran was evaluated for possible ankylosing spondylitis after reporting that a CT scan done in 2000 showed "some problems in the lower back" consistent with ankylosing spondylitis.  The Veteran also reported left sided low back pain with occasional radiation down to the top of the left foot since December 2006.  He reported being told by a neurologist at Walter Reed that this was "sciatica."  The Veteran reported that pain was relieved by exercise.  He denied any other joint pains or symptoms.  He indicated that he had been taking medication for leg pain with incomplete relief.  The Veteran reported that exercise was the main thing that helped his leg pain.  Physical examination revealed no joint swelling or tenderness to palpation.  Straight leg test was positive on the left side.  There was no tenderness to palpation of the sacroiliac joints or anywhere on the Veteran's back.  The Veteran was able to bend forward and touch his toes without difficulty.  The assessment was lower extremity pain secondary to sciatica.  

The Veteran underwent a VA examination in September 2007.  In pertinent part, he reported being diagnosed with moderate TBI with functional impairment in the form of slow speech, difficulty finding words, and some stuttering.  He also reported being diagnosed with degenerative disc disease of the lumbar spine and associated nerve disease affecting the back of his left leg from the buttocks to the foot.  There was tingling, numbness and weakness of the affected parts, but the Veteran denied abnormal sensation, anesthesia and/or paralysis of the affected parts.  The Veteran could not walk quickly and the peripheral nerve condition resulted in pain at the lower back for one year, which occurred constantly.  The pain travelled down to the lower leg, was aching and sharp in nature, and was a level seven out of 10.  Pain would be elicited by sitting for long periods and was relieved by medication.  The Veteran was able to function with medication.  Achy lower back pain stayed at a level seven with intermittent sharp pains down the leg spiking to a level 10.  Sharp pains occurred four to five times a day and were momentary.  The symptoms described occurred constantly.  Functional impairment was pain after sitting one hour and pain with bending and lifting.  

Physical examination at the time of the September 2007 VA examination revealed that the Veteran's posture and gait were within normal limits and he did not require an assistive device for ambulation.  There were signs of intervertebral disc syndrome to include sensory deficit of the left lateral thigh, motor weakness of the left hip on adduction 4/5, and sensory deficit of the left lateral leg, left dorsal foot, and left lateral foot.  Reflexes were normal on both lower extremities.  The examiner reported that the most likely peripheral nerve was the sciatic nerve and that IVDS did not cause any bowel dysfunction, bladder dysfunction, or erectile dysfunction.  Gross examination of the muscles was within normal limits.  The lumbar spine was tender to palpation at the left lumbar paraspinal muscles, but there was no radiation or spasm.  Straight leg test was positive on the left and negative on the right.  Range of motion testing revealed 90 degrees of flexion with pain at 65 degrees; 30 degrees of extension with pain at 25 degrees; right lateral flexion to 30 degrees with pain at 20 degrees; left lateral flexion to 30 degrees with pain at 30 degrees; and bilateral rotation to 30 degrees without pain.  There was no additional limitation with repetitive movement.  The diagnosis was IVDS without DJD of the lumbar spine affecting the sciatic nerve.  Subjective factors were low back pain radiating to the left leg.  Objective factors included tenderness, pain with range of motion, and sensory and motor deficits.  X-rays of the lumbar spine showed good alignment throughout with disc spaces preserved and vertebral body height maintained.  The sacroiliac joints were unremarkable.  The impression was negative lumbar spine.  

The Veteran was seen in November 2007 at Walter Reed for follow up of low back pain with radiation to his lower extremities.  He noted that he had backed off of Neurontin and was taking one to four 600mg tablets per day.  He indicated that this helps in the morning, though he felt too tired to take a mid-day dose while at work.  The Veteran would take another dose if his pain flared up during his drive home.  The Veteran continued to note no pain or numbness (though occasional tingling or buzzing in his anterior thighs or lower legs).  He was not having problems walking, going up or down steps/hills, and was not having any bowel/bladder problems.  Physical examination revealed no sensory abnormalities and the Veteran was intact to pin prick, proprioception and vibration in the bilateral lower extremities.  Motor examination revealed normal strength 5/5 throughout in the bilateral lower extremity, normal tone, normal bulk, and no tremor.  Gait was described as normal, intact, and spontaneous.  Reflexes were normal 2+ and symmetrical throughout.  The Veteran's toes were down going bilaterally.  The assessment was radiculopathy.  It was noted that the Veteran was doing well and that despite CT findings of herniated discs, he continued to have a normal neurologic exam to include intact strength and reflexes.  It was also noted that he had recently had a normal EMG, which suggested that whatever nerve root impingement is present is mild.

The Veteran was seen at Walter Reed in January 2008 with low back pain and radicular symptoms since December 2006.  The pain was constant and reported at a level four out of 10, but could be as high as a level nine.  The Veteran described it as moderate pain across the lumbar region with occasional shocks in to the left lower extremity and sometimes in the right lower extremity in the tibial area.  The pain was worse due to not being active and was better with exercise and with transient sitting.  Prolonged sitting or standing made it worse.  The Veteran reported occasional numbness in the left foot on the dorsum, but no weakness or loss of bowel or bladder control was reported.  Physical examination revealed normal movement of all extremities and full range of motion of the lumbosacral spine, though actual measurements were not provided.  Lumbosacral spine pain was not elicited by motion and straight leg raising test was negative.  Neurological examination revealed no decreased response to tactile stimulation; no observed lower extremity weakness; and normal gait and stance and deep tendon reflexes.  The assessment was lumbar radiculopathy.  The Veteran thereafter underwent epidural steroid injection.

The Veteran was seen at Walter Reed in June 2008.  A previous recurrent history of midline midback pain was noted.  Previous visit for lumbar epidural steroid injection (LESI) had benefit for one month afterward.  He was there that day for a second LESI.  The Veteran reported increase in functional status and improvement in leg pain after first injection.  He denied relief of his back pain status post epidural steroid injection (ESI).  The Veteran reported lower back pain with muscle spasm and back stiffness; he denied fecal incontinence and loss of urinary control.  The Veteran also denied numbness of the legs and straight-leg raising test was negative.  A motor exam demonstrated no dysfunction.  No lower extremity weakness was observed.  The assessment was lumbar radiculopathy and lumbago.  

The Veteran was seen at Walter Reed in July 2008 with complaint of chronic low back pain recently treated with ESI with only minor relief, though he said it had reduced the amount and severity of his pain exacerbations.  Prior trials of physical therapy had not been helpful.  The Veteran described the pain as a constant ache without numbness, though he did endorse periodic tingling in his left leg.  His pain improved with Neurontin and with physical activity and was worsened with prolonged standing.  Lumbosacral spine pain was elicited at the extreme limits of the range of passive motion, though no actual range of motion measurements were provided.  A straight-leg raising test of the left leg was positive.  The lumbosacral spine exhibited a normal appearance.  Palpation of the lumbosacral spine revealed no abnormalities.  The lumbosacral spine exhibited no muscle spasms.  Limping and an ataxic gait were observed.  The assessment was lumbar radiculopathy.  

An August 2008 record from Walter Reed reveals that the Veteran was being followed for chronic low back and leg pain in radicular pattern.  He had not had an MRI due to retained shrapnel.  The pain was greatest in the left leg, on the lateral aspect going down to the foot.  The Veteran also reported occasional "warmth" on the bottom of the foot.  The Veteran denied weakness and bowel or bladder dysfunction.  Palpation of the lumbosacral spine revealed abnormalities, specifically tenderness on palpation and muscle spasms.  A straight-leg raising test of the left leg was positive.  The lumbosacral spine exhibited no tenderness on palpation of the spinous process.  A Patrick-Fabere test was negative at the right and left sides of the sacroiliac joints.  Gaenslen's sign was not observed on either side of the sacroiliac joint.  Neurological examination was normal.  The assessment was lumbar radiculopathy.  The Veteran thereafter underwent lumbar transforaminal epidural steroid injection.  

An October 2008 health record from Walter Reed documents that the Veteran again reported pain was greatest in the left leg, on the lateral aspect going down to foot.  He again noted occasional "warmth" on the bottom of the foot.  He denied weakness and bowel or bladder dysfunction.  Palpation of the lumbosacral spine revealed abnormalities, specifically tenderness on palpation and muscle spasms.  A straight-leg raising test of the left leg was positive.  The lumbosacral spine exhibited no tenderness on palpation of the spinous process.  A Patrick-Fabere test was negative at the right side of the sacroiliac joint.  A Patrick-Fabere test was negative at the left side of the sacroiliac joint.  No sensory exam abnormalities were noted.  A motor exam demonstrated no dysfunction.  No coordination/cerebellum abnormalities were noted.  Balance, gait and stance were all normal.  Reflexes and peripheral nerves were also reported as normal.  The assessment was lumbar radiculopathy.  

An October 2008 VA polytrauma note documents that the Veteran was seen with chief complaint of back pain.  He reported pain across the waist line.  Pain was constant at a level three out of 10, aggravated to a level eight by sitting, standing and driving.  He reported sometimes experiencing an electrical shock going down the left leg posteriorly, a few times a day, and feeling numbness and tingling in the left leg.  The Veteran was reported to be status post four epidurals with limited pain relief.  He had been taking Gabapentin for one year, which had helped his left leg pain a lot.  After he started on new medication, he noticed a few twitches in the body and seeing things like somebody sitting in the car.  This happened the second day after he started the medicine; he did not have any current problems.  Physical examination revealed tenderness in the lower back with decreased range of motion, though no actual measurements were provided.  Straight leg raising test was positive in the left leg.  Strength was 5/5 in both legs and deep tendon reflexes were 2+ at both knees and ankles.  Gait was stable.  The impression was chronic low back pain with degenerative disc disease and lumbar radiculopathy.

A December 2008 VA psychiatric note documents that the Veteran continued to struggle with the adjustment following his military retirement.  He was working full time for the Department of Defense (DOD) in operations for the joint improvised explosive device (IED) task force but was planning to transition to a new job soon.  He was preoccupied with back pain and discussed his frustration with chronic back pain at least in part related to two ruptured discs.  The Veteran also continued to struggle with the transition from Walter Reed to VA and was continuing neurological care at Walter Reed.  The Veteran was unsure about his work situation and was considering a job switch but was unsure about the risks versus benefits of it.  The current workplace was filled with contractors and the Veteran found it somewhat disturbing that sometimes people just disappear from the workplace without notice, as if they were killed.  He had a two week vacation starting the next week and planned to travel with family.  The Veteran described a camping trip with his sons in August where he made some decisions out of confusion that put him and his sons in danger.  The Veteran felt angry and embarrassed about the trip.  He discussed how his memory changes make him feel emasculated, and how his wife is more distressed and angry with him than she used to be, making him feel he had exhausted her patience.  The Veteran's sleep was somewhat better now that he was taking medication.  He was getting four to five hours of interrupted sleep and also felt that increased medications had helped with anxiety and irritability.  Mental status examination revealed that the Veteran was casually dressed with good hygiene.  He reported his mood as "it's a good day overall."  Affect was mildly anxious and mildly constricted in range.  Speech was sometimes hesitant, otherwise of normal rate, volume and tone.  Thought process was circumstantial but easily redirectable.  The Veteran denied suicidal/homicidal ideation or auditory/visual hallucinations or frank paranoia.  Judgement/insight was reported as adequate for safety.  The Veteran was alert and oriented times three.  

The Veteran was seen at Walter Reed in December 2008 with complaint of chronic low back and leg pain in radicular pattern.  Pain was greatest in the left leg on the lateral aspect going down to the foot.  He also reported occasional "warmth" on the bottom of the foot.  The Veteran denied weakness and bowel/bladder dysfunction.  Physical examination revealed tenderness on palpation of the lumbosacral spine and muscle spasms.  Straight leg raising test of the left leg was positive.  A Patrick-Fabere test was negative on both sides of the sacroiliac joint.  No sensory examination abnormalities were noted; no motor examination dysfunction was demonstrated; and balance, gait and stance, reflexes and peripheral nerves were reported as normal.  The assessment was facet syndrome.  Another December 2008 record from Walter Reed captures the same complaints and objective evidence and assessed the Veteran with lumbar radiculopathy.  The Veteran thereafter received transforaminal epidural steroid injections.

A January 2009 VA neurology outpatient consult documents that the Veteran reported "sciatic like" back pain "L5 region" centrally located at "L5" with left leg numbness and shooting pain down the back of the leg to the entire foot, but spares the toes.  This occurred several times a day, was worsened by long periods of sitting idle and improved with stretching and physical activity.  The Veteran did not recall feeling back tightness or spasming.  Motor examination revealed normal tone and normal strength in left lower extremity without drift.  Deep tendon reflexes were normal on the left.  Initially, left hamstring was 4/5 secondary to pain, but was 5/5 on reattempted examination.  Sensation was equal in the left leg to light touch, pin prick and vibration; proprioception was intact in the toes.  Heel-shin-heel test was non-ataxic and non-dysmmetric bilaterally and Romberg was negative.  Gait was normal and the balls of the feet and the heels were in tandem.  The assessment was left lower extremity radiculopathy.  

A March 2009 VA psychiatry note documents that the Veteran reported regretting his irritability at home and wished for better mood stability and impulse control.  He had been trying to take Sertraline every day recently because he noticed it helped him to be more calm.  The Veteran reported his sleep was fair; he sometimes had frequent awakenings and nightmares.  Hypervigilance persisted.  The Veteran discussed workplace stressors and how difficult it is for him to tolerate the workload.  He was proud of his workgroup but also found it to be overwhelming.  Mental status examination revealed that the Veteran was casually dressed with good hygiene.  Mood was reported as "OK."  Affect was mildly constricted in range, but more calm and stable.  Speech was sometimes hesitant, otherwise normal in rate, volume and tone.  Thought process was circumstantial but easily redirectable.  The Veteran denied suicidal/homicidal ideation or auditory/visual hallucinations or frank paranoia.  Judgement/insight was noted to be adequate for safety.  The Veteran was alert and oriented times three. 

A March 2009 VA psychiatric note documents that the Veteran continued to struggle with the adjustment following his military retirement and was working full-time for the DOD in operations for the joint IED task force.  He discussed how he had transitioned his care entirely to VA now and felt comfortable that his needs could be met at VA, and that he felt particularly good about the polytrauma team.  Following a recent surgery, the Veteran insisted on returning to work after two days and did not take post-operative pain medications until he felt overwhelmed and had debilitating headaches.  With hindsight, the Veteran regretted rushing back to work as he recognized how difficult it is for him to acknowledge distress and medical illness, to comply with medications, and to give himself permission to heal.  The same complaints and mental status examination findings as in the preceding note were again reported.  

A March 2009 VA polytrauma psych note documents that the Veteran reported his mood was stable and that he felt less depressed.  Sleep was still poor with frequent nightmares.  The Veteran was not taking the Seroquel at night due to difficulty walking up and feeling hung over, but he continued on Sertraline.  Work and home life was still stressful, but the Veteran thought he was doing better at managing the stress.  He was trying to get regular exercise.  The Veteran talked about friend who suicided two months ago and stated "we didn't see it coming."  The Veteran reported he was still withdrawn and did not like to go out with friends since "they always ask how I'm doing, it is hard to talk about."  The therapist discussed thinking of answers to some of the routine questions before going out, then just using the pre-decided on answer when confronted with uncomfortable questions.  The Veteran denied suicidal ideation, intent or plan.

A May 2009 VA psychiatry note documents that the Veteran described his overall mood as overwhelmed and that he was "trying hard to keep up" with life issues.  It was noted that the Veteran and his wife were struggling with their l5 year old son, who was engaged in some risky behaviors.  It was noted that they were on a wait list for counseling services.  The Veteran indicated that he was so busy with work and family obligations that he had difficulty feeling at all balanced.  He had been avoiding social interactions and could not find much personal time to exercise at home.  Mental status examination revealed that he was casually dressed with good hygiene.  Mood was reported as "struggling to keep up."  Affect was mildly constricted in range, but more calm and stable.  Speech was sometimes hesitant, but otherwise of normal rate, volume and tone.  Thought process was circumstantial but easily redirectable.  The Veteran denied suicidal/homicidal ideation or auditory/visual hallucinations or frank paranoia.  Judgement/insight was adequate for safety.  The Veteran was alert and oriented times three. 

The Veteran underwent a VA examination on May 27, 2009.  In pertinent part, he reported numbness in the left leg, tingling in the left leg to the foot, and weakness in the left leg without medications.  He also described sciatica pain in the left leg.  The Veteran also reported mood swings, confusion, slowness of thought, problems with attention/concentration, difficulty understanding directions, problems with reading (cannot stay on line or read out loud), problems with anxiety (gets very tense and quick to anger), depression and feeling unmotivated and numb, moderate short-term memory problem, and difficulty finding words.  The Veteran reported symptoms of fatigue, described as feeling tired constantly or sick; experiencing smell/taste problems described as poor sense; hypersensitivity to light causing pain; irritability described as getting angry fast; restlessness; and a general feeling of discomfort.  He reported pain in the lumbar area and left leg, which occurred constantly and was of a level five in severity.  The Veteran denied sensitivity to sound, heat intolerance, abnormal sweating, and/or trouble sleeping.  He also denied experiencing any seizures, but reported difficulties in finding the right words to say, with processing sounds or forming words, and with speech, which he described as word finding difficulty.  The Veteran also denied bladder or bowel problems and impotence.  He reported functional impairment in the form of being unable to stand for long periods due to pain.  

Physical examination at the time of the May 2009 VA examination revealed that posture was normal, but the Veteran walked with a limp to the left, which resulted in a tandem gait.  The Veteran had no difficulty with weight bearing, balancing, or with ambulation and did not require any assistive device for ambulation.  Neurological examination of the lower extremities revealed that motor function and sensory function were within normal limits.  Reflex examination was normal on both sides and peripheral nerve involvement was not evident during examination.  In an addendum, the examiner clarified that the Veteran's speech was normal.  

The Veteran also underwent a VA psychiatric examination in May 2009, at which time he reported having more unpleasant dreams lately and poor sleep, but that his anger management had improved and that his symptoms had been mostly about the same since he first received treatment.  The Veteran indicated that he had no interest in people or friends, that he had been married for 22 years but did a lot of arguing and fighting with his wife, and that he was working as a consultant to an IED task force.  He indicated that he got very upset from the casualty reports that he has to review each day and that he had been having problems sleeping for two years.  Since his discharge from service, the Veteran had continued to have feelings of PTSD and felt sick all of the time.  He reported that he had two siblings and got along with one, but not the other.  The Veteran had had some changes in his daily activities in that he had no patience with people and got irritable and could be outspoken.  He had feelings of hostility and had had social changes and had no desire to go out, meet or talk with friends, and occasionally has blow ups with almost anybody, but had been better on medication.  The Veteran reported recurrent recollections of the in-service trauma and distressing dreams.  He also felt that it was recurring and had some physiological reactivity caused by his dreams.  The examiner noted this was basically feelings of anxiety.  

Mental status examination at the time of the May 2009 VA examination revealed that the Veteran appeared to be a reliable historian who was alert and cooperative.  He was well oriented and had normal appearance and hygiene.  His behavior was appropriate with good eye contact.  Affect and mood appeared normal and communication and speech were normal.  The Veteran reported that his concentration was impaired and he had poor attention and focusing.  He denied panic attacks, but indicated he had no trust in people and was suspicious.  There were no delusions, hallucinations, or obsessional rituals.  Thought processes were normal and there was no impairment of abstract thinking.  The Veteran's judgment was somewhat impaired and he said his spending habits were poor.  The Veteran also felt his memory was poor with difficulty with names and directions.  He could remember places and dates fairly well.  There was no suicidal or homicidal ideation and the Veteran appeared to have the behavioral and cognitive changes, as well as the social and affective changes, secondary to PTSD.  

Cognitive examination at the time of the May 2009 VA examination reveals that the Veteran reported he could not set goals and monitor himself.  Other than that, he felt that he could not plan, organize or prioritize.  He also had trouble solving problems, making decisions, being spontaneous, and exercising good judgment.  He felt that he was not flexible in changing his actions.  The Veteran also thought his processing of information was delayed.  The examiner noted this may be secondary to mild visual problems, which may be secondary to an eye imbalance secondary to the trauma.  The Veteran claimed memory loss, but the examiner indicated it did not appear intense as he could recall six digits.  The Veteran also claimed that he can recall concentration problems, but no attention difficulties.  He had mild memory changes.  When asked to recall the examiner's name, he could not.  The examiner noted moderately impaired judgment, especially with financial affairs.  His social activities could be inappropriate due to his anger.  He was always oriented.  Motor activity was normal and visual spatial orientation appeared normal.  The Veteran had some problems that may interfere with his life, such as a possible divorce and that he had no close relationships.  He had some problems with workplace and social interaction, which was mainly due to anger problems, difficulty getting close to people, and suspiciousness.  The Veteran had some neuro-behavioral effects that could interfere with his workplace and social interaction occasionally, but he was noted to be able to communicate well with written and spoken language.  The examiner reported slight changes secondary to TBI.  Axis I diagnoses of chronic PTSD and cognitive disorder secondary to TBI were provided and a GAF range of 50-55 was assigned.  

VA treatment records document that the Veteran traveled with his family to Colorado and Maine in July 2009.

A September 2009 VA psychiatry note documents that the Veteran was working in an IED TASK force and was also going to school online for business management.  He had kids that he spent time with as much as he could.  He indicated that his PTSD symptoms had been up and down.  The Veteran reported that he felt mildly depressed and thought it was because it is the anniversary of when he got injured.  He reported taking medications without any significant side effects.  Mental status examination revealed that the Veteran was cooperative with regular rate and rhythm of speech.  Mood was mildly depressed, affect was congruent to mood, thought process was linear, thought content revealed no intent or plan (suicidal and homicidal), no auditory or visual hallucinations, fair insight/judgment and that the Veteran was alert and fully oriented.  

An October 2009 VA psychiatry note documents that mental status examination revealed that the Veteran was cooperative with regular rate and rhythm of speech.  Mood was euthymic, affect was congruent to mood, thought process was linear, thought content revealed no intent or plan (suicidal and homicidal), no auditory or visual hallucinations, fair insight/judgment and that the Veteran was alert and fully oriented.  

VA treatment records document that the veteran attended a community reintegration outing to Black Hill Regional Park in October 2009.

A November 20009 letter from VA clinical psychologist Dr. S.M. reports that the Veteran had been functioning as a competent member of society.  In her/his experience, the most useful assessment of competency is how an individual functions in the real world.  Dr. M. reported that the Veteran was employed full time and financially provided for his family.  He was actively involved in the parenting of his two teenage sons.  His wife handled the family finances, which she also did prior to his injury.  He was an advocate for other Wounded Warriors by providing both emotional support as well as resources to other Veterans.

A November 2009 letter from VA speech-language pathologist P.M.H. reports that s/he had worked with the Veteran since November 9, 2007.  In that time, s/he had found him to be thoughtful and insightful about his mild cognitive-communication impairments and to work hard towards improving them.  During those two years, the Veteran had undergone the transformation from military to civilian and had sought to improve the lives of other soldiers enduring the same.  He had served on a VA-DOD Task Force on caregiver education and presented at a state TBI administrators conference.  He had also served on focus groups and made videos for the VA.  He had held a full-time demanding job while doing all of the above, attending therapies, and taking graduate level classes.  Latest testing (11/10/09) documented that the Veteran was capable of completing addition and subtraction problems independently with 100% accuracy without using a calculator.  Testing also involving word retrieval and reading comprehension of lengthy materials continues to document deficits.  He scored 43/60 on the Boston Naming Test, where the mean is 55; he tried to compensate in conversation by using descriptions, but if he is asked questions during a presentation or discussion, he is apt to become tangential and have difficulty remembering his topic.  He was given verbal directions for a reading test, which was printed with a vocabulary test on the opposite pages, and became confused by the visual presentation, flipping the pages to work on both the reading and the vocabulary tests.  As a result, the Veteran was unable to complete either of the tests.  It was noted to take him multiple readings to be able to comprehend articles at work or for class; he will persevere, but it takes him much longer than it would a co-worker. 

An undated letter received by fax in November 2009 from VA physician S.K. reports that the Veteran sustained a TBI resulting in mild cognitive-communication impairments.  Dr. K. reported that the Veteran was well aware of his deficits and had developed strategies to compensate for his deficits.  Dr. K. reported that the Veteran had been functioning as a competent member of society and employed full time.  He was also an advocate for other wounded warriors.

A January 2010 VA polytrauma note documents that the Veteran continued to take on many activities, along with school and work, which was difficult to balance.  The Veteran reported that he was going to be going to New York with his youngest son for a hockey-related event.  He also planned to take part in a Wounded Warrior ice hockey team.

A January 2010 VA mental health note documents that the Veteran was alert, oriented, engaging and cooperative.  Current symptoms included memory problems or lapses; balance problems or dizziness; sensitivity to bright light; irritability; headaches; and sleep problems.

A January 2010 VA treatment record documents that the Veteran shared pictures of his latest camping trip in the snow with his brother- in-law.

A January 2010 VA psychiatry note documents that mental status evaluation revealed cooperative demeanor; speech of regular rate and rhythm; and motor functioning within normal limits.  Mood was reported as "okay" and affect was congruent to mood.  Thought processes were linear and the Veteran denied any suicidal or homicidal ideation, intent or plan.  There was no evidence of auditory or visual hallucinations; insight and judgment were fair; and the Veteran was alert and oriented fully.  A GAF score of 60 assigned.  

A February 2010 VA polytrauma note documents that the Veteran left a message that he had run out of Zoloft and had an outburst of anger at something his son had done.  He reported that he punched a wall and put his fist through it.  He reported that this was scary behavior, and his anger is usually under control when he is on his Zoloft.  In this case, he had forgotten to order the medication and was without it for three days.

A February 2010 VA physical medicine rehab outpatient note documents that the Veteran was seen with chief complaint of back and left leg pain.  The back pain was accompanied with weakness on left side.  On average, the pain was at a level four out of 10.  At worst, it was at a level six.  Pain was better if he exercised.  The Veteran denied a worsening of symptoms.  Physical examination revealed slightly decreased sensation to light touch and pinprick.  Deep tendon reflexes were intact 2/2.

A June 2010 VA polytrauma psych note documents that the Veteran continued to report sleep disturbance with difficulty initiating and maintaining sleep.  He reported emotional numbing, which affected his relationship with his wife.  He stated "nothing seems to spark anymore" and ''I'm too impatient, I am not a good. listener, I don't work at the marriage, I don't feel like I have anything to give."  The Veteran also reported difficulty with impulse control.  For example, on one occasion, he was picking his son and some of his son's friends and after he pulled up, the car behind him starting honking the horn and then pulled around the Veteran's car and began shouting at the Veteran before driving away.  The Veteran stated he "took off after the driver" then heard his son yelling at him to stop.  The Veteran pulled over and realized that he had his son and one of his son's friends in the car, but had left the other two friends standing on the curb.  The Veteran reported trying to remove himself from the situation rather than react and that he had been doing better in avoiding confrontations.  He also continued to have difficulty with decision making.  For example, he reported recently ordering $1,600 worth of ammunition, but that his wire cancelled the order.  He had also tried to buy a new vehicle and to rent an apartment closer to his work.  The Veteran was aware that these decisions were impulsive.  The Veteran also reported difficulty with planning and organization.  For example, if he had to reschedule an appointment or meeting, he will look at his calendar but could not figure out what he needed to change.  The Veteran reported being married and living with his wife and two sons.  He was employed as a government contractor.  The Veteran indicated that his symptoms had caused problems in his relationships and in employment.  He reported getting together occasionally with "Army buddies," but generally did not socialize or engage in recreational activities.  He had gone camping by himself and with his sons, but his cognitive problems had made it more difficult in terms of planning and executing a plan regarding a camping trip.  The Veteran reported he would often work late when it is quieter and there are less distractions.  He had difficulty with fatigue and at times will have to pull over to rest when driving home from work.  

Mental status evaluation in June 2010 revealed that he was casually dressed and well groomed.  Speech was logical and coherent, but it was noted that speech was slow and hesitant at times.  The Veteran appeared fatigued.  Eye contact was fair and the Veteran was oriented to person, place and time.  He exhibited decreased concentration and reported moderate short term memory problems.  Thought processes were within normal limits and the Veteran was aware of his deficits.  He reported trouble falling asleep (waking up and not being able to fall back to sleep) and experiencing frequent nightmares.  Appetite was within normal limits and energy was fair, though the Veteran fatigued easily.  He reported moderate anxiety and problems with anger in the form of verbal conflicts.  Affect was blunted and the Veteran's mood was anxious and depressed. The Veteran denied suicidal/homicidal ideation.  A GAF score of 48 was assigned.  

An undated letter from Dr. S.K. faxed in June 2010 reports that the Veteran had been under his/her care since 2008 and suffered from short term memory problems, poor concentration, was easily distractible, and had difficulty with multi-tasking.  It was noted that a recent PET scan of his brain showed that the metabolism on his right side was slower than the left side, which would explain his cognitive problems.  It was noted that the Veteran had been followed by the poly trauma team for several years and still participated in cognitive therapy to work on cognitive and communicative problems.  He was working with some accommodations at that time, but worked extra hard (with many extra hours) to keep up at his work place.  Dr. K. also reported that MRI of the back showed disc protrusion pressing on the nerve, which happens in injuries like he experienced.  Because of the back pain, the Veteran could not sit or stand for long periods of time and he had to keep changing his position to get comfortable.  His participation in many recreational activities with his family had been decreased due this chronic back pain.  Dr. K. indicated that the Veteran was not a candidate to take pain medicines on a regular basis due to his cognitive problems.  It was also noted he had undergone multiple injections for his back pain.  

VA treatment records document that the Veteran participated in a biathlon with his wife in October 2010.

A January 2011 VA psychiatry note documents that the Veteran described many psychosocial stressors the week before Christmas, including a car dying, having to put the family dog down, a cell phone dying and a computer dying.  He then went on vacation to Germany/Austria with his family, which he enjoyed.  The Veteran also reported that he finished his master's degree with a GPA of 3.5 and was working with vocational rehabilitation services to find a federal service job.  The Veteran denied any symptoms of needing to move his legs around due to uncomfortable/painful sensations and reports during the sleep study he moved his legs around because of sciatic pain.  Mental status examination revealed cooperative demeanor and speech of regular rhythm and rate.  The Veteran described his mood as "low at times due to psychosocial stressors but I'm okay."  Affect was congruent to mood; thought processes were linear; insight and judgment were fair, and the Veteran was alert and oriented fully.  He denied any suicidal or homicidal ideation, intent or plan and also denied any audio or visual hallucinations.  

The Veteran underwent a VA mental disorders examination on January 18, 2011.  Subjective complaints included occasionally zoning out; getting confused about where he was going and why; dislike of being around people, in part due to discomfort; depression; and a lack of desire to do the things he used to.  The Veteran reported that he was working as a contract consultant with DOD, but had missed a significant amount of time in the last year as a result of his mental disorder.  More specifically, he reported missing approximately seven weeks during the last year for medical appointments and difficulties associated with his TBI and mental disorder.  Regarding work performance, the Veteran reported that he was not happy with it and did not feel he put the level of effort into it that he used to be able to contribute.  The examiner reported that as documented in a separate VA examination, the Veteran's TBI has a substantial impact on his work performance and history.  The examiner also reported that more likely than not, the Veteran's depression and PTSD symptoms also have a moderate impact on occupational functioning. The Veteran reported that he had been married for 23 years and had two teenaged sons, ages 17 and 15.  He reported his relationship with his wife as fair.  His wife, who was present at the examination, stated "if he is having a bad day, he makes us all have a bad day."  She reported that the Veteran will frequently withdraw from his wife and kids.  Regarding his relationship with his children, the Veteran noted it was fair.  He indicated that it was "stressful" and that he had a number of parenting challenges and got down on himself and frustrated in his relationship with his children.  The Veteran reported having some friends, but indicated that he did not seem them on a frequent basis, estimating typical contact about three times per year.  He reported frequent isolation and withdrawing from social relationships.  The Veteran indicated that he was no longer able to participate in many of the social activities and leisure pursuits that he previously enjoyed.  He noted that he did not like large crowds and avoided malls and sports complexes.  He reported feeling a diminished sense of enjoyment in things that he previously liked to do, though he did enjoy some things, like recently taking his children on a snowboarding trip.  The Veteran reported chronic and pervasive problems with becoming verbally and, at times, physically aggressive with others.  Over the past year, he reported one physical altercation.  He denied any legal or other consequences resulting from this.  He reported that he often felt irritable with others, loses patience, and will snap at people or things that get frustrated.

Mental status examination at the time of the January 2011 VA examination revealed that the Veteran's appearance, grooming and psychomotor activity were within normal limits.  The Veteran reported some visual hallucinatory experiences and reported having a hallucination of "rats running across my dash at times," although he noted that it had been a while since this occurred.  He also reported more frequently (several times a week) "seeing" a dark silhouette in the back seat of his car.  The examiner reported that the Veteran's behavior in the session was appropriate; that there were no current suicidal thoughts, ideation, plan or intent; that there were no past suicidal or homicidal thoughts, ideation, plan or intent; that the Veteran was able to maintain personal hygiene and basic activities of daily living; that the Veteran was oriented to person, place and time; and that there were no obsessive or ritualistic behavior that interfered with routine activities.  The examiner noted that the Veteran's rate and flow of speech was normal and that there were no panic attacks present.  The Veteran reported the presence of depressed mood and other depressive symptoms and that he did not want to participate in group activities.  The examiner noted that these symptoms of interpersonal withdrawal and impairment of motivation appeared to be a consistent symptom of his depression.  The Veteran described experiencing a "constant" depressed mood, which he described as "a little bit of sadness."  He reported feeling frequent guilt and blaming himself for negative events in the past and current challenges.  He indicated "I don't feel a sense of pride or accomplishment in things now," and that he experienced feelings of worthlessness at times.  There was some anhedonia as the Veteran reported "I don't enjoy sports or movies like I used to."  He denied suicidal ideation.  The examiner reported that results of the evaluation were consistent with the diagnosis of depression, not otherwise specifies.  The examiner reported that the Veteran experienced moderate to severe impairment in social and occupational roles due to impaired impulse control.  The Veteran also had sleep impairment in the form of chronic insomnia, reporting sleeping in the range of three to four hours per night.  

The January 2011 VA mental disorders examiner reported that over the past year, the Veteran had psychiatric symptoms present; that they were of moderate severity; that they were chronic and continuous; and that there had been no remission.  In terms of social functioning, the Veteran isolated himself but was capable of basic activities of daily living.  The following areas were currently affected by the psychiatric symptoms: employment (moderate); activities of daily living (mild to moderate); routine responsibilities (moderate); family role (moderate to severe); physical health (moderate); relationships (moderate); leisure activities (moderate); and quality of life (moderate to severe).  It was noted that the Veteran was currently employed, but experiencing substantial impairment in occupational functioning due to mental disorders.  Axis I diagnoses of depression, not otherwise specified; and PTSD were provided and a GAF score of 51 was assigned.  

The Veteran also underwent a VA TBI examination on January 18, 2011.  His medical history was reported and documented and a physical examination was conducted.  Reflex examination was normal on both sides.  Sensory examination revealed normal sensation to vibration and position sense in the upper and lower extremities, but decreased sensation to pain or pinprick in the left upper and lower extremities and decreased sensation to light touch in the right upper and lower extremities.  There was no dysesthesias.  Motor examination revealed active movement against full resistance on both sides for all movements; normal muscle tone; and the absence of muscle atrophy.  The examiner indicated there were no physical findings of autonomic nervous system impairment; imbalance or tremors; muscle atrophy or loss of muscle tone; spasticity or rigidity; fasciculations; cranial nerve dysfunction; endocrine dysfunction, or skin breakdown.  The Veteran had tandem gait with difficulty.  The examiner noted a complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items) attention, concentration, or executive functions, but without objective evidence on testing; moderately impaired judgment (for complex or unfamiliar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision, although has little difficulty with simple decisions); frequently inappropriate social interaction; occasionally disoriented to one of the four aspects; normal motor activity most of the time, but mildly slowed at times due to apraxia (inability to perform previously learned motor activities, despite normal motor function); moderately impaired visual spatial orientation (usually gets lost in unfamiliar surroundings, has difficulty reading maps, following directions, and judging distance; has difficulty using assistive devices such as GPS); and only occasional impairment of communication.  The Veteran's consciousness was normal.  The Veteran's wife, who was present for the examination, indicated that the Veteran was functioning at a 7th grade level and that his long term memory was impaired.  She did not believe he was stable, and was instead worsening.  The diagnosis was TBI.  There were effects on the Veteran's usual occupation and resulting work problems in the form of being assigned different duties, increased tardiness, and increased absenteeism.  There were also effects on occupational activities due to memory loss, decreased concentration, inappropriate behavior, poor social interactions, difficulty following instructions, decreased mobility, speech difficulty, hearing difficulty, decreased strength in the upper and lower extremities, and pain.  There were also effects on the Veteran's usual daily activities as he could not drive without getting lost, could not play with or coach his children, avoided social gatherings, and did not run or exercise.  The Veteran's wife reported that he did not help with cooking or cleaning and that he disturbed his family by making too much noise at night.  

The Veteran also underwent a VA spine examination on January 18, 2011, at which time he reported flare-ups of low back pain that were severe and lasting hours on a weekly basis with resulting functional impairment in the form of limited mobility.  The Veteran denied urinary incontinence, urgency, retention requiring catheterization, and frequency; nocturia; fecal incontinence; obstipation; falls and unsteadiness.  He asserted he had erectile dysfunction; numbness; paresthesias; and left sided numbness and weakness.  The Veteran also reported a history of fatigue, decreased motion, stiffness, weakness, spasm and pain.  The pain was described as sharp, severe, constant, and occurring daily.  There was sharp radiation of pain to the right leg.  The Veteran denied the use of devices/aids and indicated that he was only able to walk one quarter of a mile.  Physical examination revealed normal posture, head position, and gait, and there was symmetry in appearance.  There was no gibbus, kyphosis, lumbar lordosis, lumbar flattening, reverse lordosis, list, scoliosis, or thoracolumbar spine ankylosis.  There were no objective abnormalities of thoracolumbar sacrospinalis such as spasm, atrophy, guarding, pain with motion, tenderness or weakness.  Range of motion testing revealed flexion to 50 degrees; extension to 30 degrees; left lateral flexion to 30 degrees; left lateral rotation to 30 degrees; right lateral flexion to 20 degrees; and right lateral rotation to 20 degrees.  There was objective evidence of pain on active range of motion and following repetitive motion, but no additional limitations after three repetitions of range of motion.  Reflex examination was normal on both sides.  Sensory examination revealed normal sensation to vibration and position sense in the upper and lower extremities, but decreased sensation to pain or pinprick in the left upper and lower extremities and decreased sensation to light touch in the right upper and lower extremities.  There was no dysesthesias.  Motor examination revealed active movement against full resistance on both sides for all movements; normal muscle tone; and the absence of muscle atrophy.  Lasegue's sign was positive bilaterally.  The findings of an April 2010 MRI of the lumbar spine were reported, to include an impression of multilevel degenerative changes, extruded disc fragment at L4-5 on the right impinging on the L5 nerve root in the lateral recess, foraminal stenosis, and vertebral lesions, likely representing atypical benign lipid-poor hemangiomas.  The diagnosis provided at the time of the January 2011 VA spine examination was multilevel degenerative joint disease with disc fragment right L5 nerve root causing right L5 radiculopathy.  This had affected the Veteran's occupation resulting in the assignment of different duties, increased tardiness, and increased absenteeism.  It had also affected the Veteran's occupational activities in the form of decreased mobility; problems with lifting and carrying; decreased strength; lower extremity problems; and pain.  There were also effects on usual daily activities in the form of being unable to sit or stand for a long time, being unable to life and carry, and being unable to climb ladders.

A March 2011 VA psychiatric progress note documents that the Veteran reported having a heavy workload and having difficulty saying no to commitments.  The importance of balance in his life was discussed.  The Veteran reported that he did not feel like he wanted to be in his marriage anymore, but had not talked to his wife about it.  Mental status examination revealed that he was casually dressed with good hygiene.  Mood was "a little depressed" and affect was restricted.  Speech was of normal rate, volume and tone; thought process was goal directed; there was no evidence of auditory/visual hallucinations or delusions; insight/judgement were good; and the Veteran was grossly alert and oriented.  He also denied suicidal or homicidal ideation, intent and plan.  The assessment was PTSD; postconcussion syndrome; and depression, not otherwise specified.

A June 2011 VA psychiatric progress note documents that the Veteran endorsed seeing a shadow in his peripheral vision, but when he turns, there is nothing there.  This had been occurring since April 2011 and occurred about twice a week and only when fatigued.  He did not relate seeing shadows to hypervigilance, which was noted to be longstanding but not worsening.  The Veteran denied suicidal and homicidal ideation, auditory hallucination, and other visual hallucination.  Mental status examination revealed fair grooming and hygiene; cooperative demeanor; and speech of regular rhythm and rate.  The Veteran reported his mood was ok and his affect was congruent to mood.  Thought process was linear and there were no auditory hallucinations or delusions.  The Veteran denied suicidal and homicidal ideation, intent and plan; insight and judgment were fair, and the Veteran was alert and oriented grossly.  The assessment was PTSD; postconcussion syndrome; depression, not otherwise specified; and possible visual hallucinations.  The examiner noted that the visual hallucinations reported did not sound psychiatric and most likely were related to the TBI and vision problems exacerbated by fatigue. 

A July 2011 VA neurology outpatient consult reveals that the Veteran was seen with chief complaint of low back pain radiating to his right lower extremity.  The Veteran indicated that he had had a recent severe exacerbation of his chronic low back pain with radiation to his right buttock and lateral thigh with numbness extending to his anterior right shin.  He described his low back pain at a level 10 and reported it was sharp-to-achy with constant sharp pain to his right lower extremity.  The pain in his right lower extremity was made worse by transitioning from position-to-position.  He had not been to physical therapy but was receiving a lumbar epidural steroid injection that day.  The Veteran denied any changes in or loss of bowel or bladder control.  Physical examination revealed that the lumbar spinous processes were nontender and the paraspinous muscles were nontender without spasm.  The greater trochanters, sciaticas, and ischial tuberosities were also nontender.   Range of motion of the lumbar back appeared to be full with pain expressed in all planes of movement (flexion, extension, lateral bending and rotation), but no actual measurements were provided.  Motor strength was normal bilaterally on examination.  Sensory examination revealed that the Veteran was intact to light touch, sharp and vibratory stimuli.  Deep tendon reflexes were absent at the bilateral ankle (S1), diminished on right at patellar (L4) and normal on left at patellar.  Straight leg raise testing produced pain to the posterior right leg and lower back.  Patrick's maneuver did not produce pain.  Gait was unimpeded, there was no toe drop, and the Veteran walked with the assistance of a cane.  Tandem walk was abnormal but heel and toe walking were intact.  

A July 2011 VA polytrauma note documents a chief complaint of acute back pain.  It was noted he had chronic back pain usually radiating to the left leg, but had had a couple of days with pain in the right lower back going to the side of the thigh up to the knee.  Physical examination revealed that the Veteran was tender along the right quadratus muscle.  There was pain with right lateral bending and rotation and pain radiated to the buttock on palpation of a trigger point.  Sensation was intact.  Deep tendon reflexes were 2+ and intact.  The impression was back strain and an injection was administered.

A July 2011 VA polytrauma note documents a chief complaint of worsening leg pain and difficulty walking up and down the stairs.  The Veteran could also not walk more than 100 feet.  He denied bowel and bladder incontinence.  He indicated his pain was mainly in the right leg on the side of the leg up to the knee, going a little bit into the calf.  The pain was described as like a deep tooth ache and was worse with standing.  Physical examination revealed that the Veteran was ambulating with slight limp and had difficulty getting up from the chair, though once up, was able to walk better.  His back was less tense but had pain radiating into the leg with lateral bending.  Sensation was intact for light touch.  Pinprick was slightly decreased over the thigh and medial thigh.  Deep tendon reflexes were 1+ in the right knee and 2+ on the left side.  Ankle reflex were slightly decreased on the right side.  Strength was difficult asses due to pain, but definitely weaker on the right side in all groups as compared to the left side.  The impression was lumbar radiculopathy L3 and L4 distribution.  

A July 2011 VA neurology outpatient consult revealed that posture and stance showed level hips and shoulders.  The lumbar spinous processes were nontender, the paraspinous muscles were nontender without spasm, the greater trochanters were nontender, the sciaticas were nontender, and the ischial tuberosities were nontender.  Range of motion of the lumbar back appeared to be full with pain expressed in all planes of movement (flexion, extension, lateral bending and rotation), though no actual measurements were provided.  Motor strength was normal on examination.  Sensory examination revealed that the Veteran was intact to light touch, sharp and vibratory stimuli.  Deep tendon reflexes were absent in the ankles (S1), diminished in the right patella (L4) 1+ and normal in the left patella.  Straight leg raises produced pain to the posterior right leg and lower back.  Patrick's maneuver did not produce pain.  Gait was unimpeded, there was no toe drop, and the Veteran walked with the assistance of a cane.  Tandem gait was abnormal but heel and toe walking was intact.  

A July 2011 MRI was reported as contained an impression of L4-L5 sequestered disc fragment in the right neural foramen causing severe right neural foraminal narrowing.  Correlation with right L4 radicular symptoms would be helpful.  This disc fragment was present on prior examination (4/20/2010), but currently appears more lateral and in the neural foramen than on previous examination.

A July 2011 VA pain procedure note documents that the Veteran presented with acute exacerbation of chronic low back pain.  Physical examination revealed that the back was nontender but the Veteran had weak right hip flexor and right knee extensor.  L4 was 2+ left and zero on the right.  S1 was 2+ bilaterally.  A selective nerve root block, right L4 was performed.  

A July 2011 VA physical medicine rehab outpatient note documents that the Veteran was seen for a follow up visit and reported pain at a level 10 in the leg when he stands up.  Back pain was at a level eight.  Pain radiated up to the knee, but numbness went into the calf and dorsum of the foot.  The Veteran denied bowel and bladder problems.  Physical examination revealed difficulty laying supine and getting up from the chair.  The lumbar paraspinal muscles were still tender and there was pain with lumbar flexion and extension.  Strength was slightly diminished with knee extensors and dorsiflexors and great toe extension.  Deep tendon reflexes were 1+ on the right side and 2+ on left.  Gait was antalgesic.  The impression was L4 lumbar radiculopathy with old disc extrusion impinging on nerve root.

A July 2011 attending physician's statement of functionality prepared by a VA physician reports a primary diagnosis of lumbar disc herniation and secondary diagnoses of lumbar radiculopathy and acute back pain with muscle spasms.  Subjective symptoms included severe pain in the lower back and right leg with difficulty getting up from a chair, problems ambulating, and weakness and numbness.  Physical examination revealed very tender lumbar muscles, limited lumbar flexion and extension, though no actual measurements were provided, positive straight leg raise, decreased knee reflexes, and weakness in the right leg muscles.  It was noted that the Veteran had stopped working on July 12, 2011, and was expected to return to work on September 5, 2011.  

An August 2011 VA physical medicine rehab outpatient note documents that examination revealed difficulty laying supine and getting up from the chair.  The lumbar paraspinal muscles were still tender and there was pain with lumbar flexion and extension.  Strength was slightly diminished with knee extensors and dorsiflexors and great toe extension.  Deep tendon reflexes were 1+ on the right side and 2+ on left.  Gait was antalgesic.  The impression was L4 lumbar radiculopathy with old disc extrusion impinging on nerve root.

A September 2011 VA neurology outpatient consult documents the Veteran's complaint of low back pain radiating to the right lower extremity.  He denied any changes in or loss of bowel or bladder control.  Physical examination revealed that the lumbar spinous processes were nontender, the paraspinous muscles were nontender without spasm, and the greater trochanters, sciaticas, and ischial tuberosities were nontender.  Range of motion of the lumbar back appeared to be full with pain expressed in all planes of movement (flexion, extension, lateral bending and rotation, but no actual measurements were provided.  Motor examination revealed full strength in both lower extremities.  Sensation was intact to light touch and sharp stimuli and deep tendon reflexes were 2+ in the patellar (L4) and 1+ in the ankle (S1), bilaterally.  Straight leg raise testing produced pain to the posterior right leg and lower back.  Patrick's maneuver did not produce pain.  Gait was unimpeded, there was no toe drop, and the Veteran walked with the assistance of a cane.  Tandem gait was abnormal but heel and toe walking were intact.

A September 2011 VA psychiatry note documents that the Veteran reported he was very worried about his marriage and wanted to go to therapy, but his wife had been resistant.  The Veteran reported that he had had multiple stressors with his son, marriage, finances, medical problems and that due to multiple psychosocial stressors, he had not been sleeping well.  The Veteran indicated that he had gone two to three days without sleep and then sleeps heavily.  The Veteran stated he tried to take guns over to a friend's place, but his wife did not like the idea and she did not think it made sense logistically.  The Veteran indicated that he did not argue back because he did not want to "rock the boat."  Mental status examination revealed fair grooming and hygiene.  Demeanor was cooperative and speech was of regular rate and rhythm.  Mood was stressed and affect was congruent to mood.  Thought process was linear.  Thought content was noted as "wouldn't care if today was my last day," but the Veteran denied any suicidal or homicidal ideation, intent or plan.  The Veteran also denied auditory hallucinations and delusions, but endorsed seeing something move by on his peripheral vision on the right side but when he looks nothing is there.  This had been going on for a few years and was going on before a June 2010 brain MRI, which was normal.  It had not worsened since.  The Veteran attributed it to eye problems related to his TBI.  Insight and judgment were fair and the Veteran was alert and oriented grossly.  The assessment was PTSD; postconcussion syndrome; depression; insomnia, and anxiety disorder, not otherwise specified.  It was noted that the reported shadows in the Veteran's peripheral vision did not sound psychiatric and most likely were related to the TBI and vision problems exacerbated by fatigue.  

A September 2011 VA polytrauma psych note documents that the Veteran reported increased stress at home and increased conflict with his wife.  The Veteran had discovered his wife had been emailing with a male, married co-worker and was concerned due the frequency of contact.  His wife reported that the co-worker was just a friend who also had teenagers and she could talk to him about issues.  The Veteran had been using his military skills to obtain additional information about the co-worker and stated he thought about causing the co-worker problems, but denied intent to physically harm the co-worker.  The Veteran reported that his wife reportedly had an affair several years ago, when they had been married for five years, and that he had forgiven his wife, but the memory made it more difficult to deal with the current situation.  The Veteran expressed concern about anger and not wanting to hurt his wife.  He also reported all the guns, except two, were locked up in the house and that he had hidden the key and did not remember where it was.  One of the guns that is not locked was his wife's gun.  The Veteran agreed to remove all the guns from the house and take them to a friend's house.  The Veteran reported having increased problems sleeping, to include going two to three days with only two hours of sleep.  He also reported an increase in nightmares, decreased appetite (eating once a day), and concern about financial issues.  

The Veteran was seen at Walter Reed in September 2011 with chief complaint of low back and right leg pain and weakness.  His left leg pain had resolved since injection but his right leg symptoms had worsened and now his right leg was weak and had given out a couple of times.  He had the most difficulty in walking down steps or down a hill when the right leg was likely to give out.  The Veteran reported using a cane since July 2011.  He indicated he had pain and numbness following a strip down his buttock and around the outside of the thigh and across the knee to the inside of his lower leg down toward the ankle.  Physical examination revealed that the Veteran appeared uncomfortable.  The lumbosacral spine did not demonstrate full range of motion, but no actual measurements were provided.  Lumbosacral spine pain was elicited by motion.  Straight leg raise and sitting root tests of the right leg were positive, but reverse straight leg raising test on the right leg was negative.  Palpation of the lumbosacral spine revealed no abnormalities.   Straight leg raise and reverse straight leg raise tests on the left leg were negative.  Sensory examination abnormalities were noted in decreased touch sensation in L4 and L5 on the right.  A motor examination demonstrated dysfunction 4/5 in the right quadriceps and 4/5 in the right extensor hallucis longus.  Gait was reported as abnormal due to walking with a cane and limping was observed.  Heel and toe walking were normal.  Right knee jerk reflex was absent but left knee jerk and bilateral ankle jerk reflexes were normal.  An MRI performed by VA was reviewed and noted to show far lateral calcified disc protrusion at L4-5 on the right with prodominant L4 root impingement and possible L5 impingement as well.  There was degenerative disc disease at L5-S1 and Scheuermann's disease in high lumbar and visible thoracic spine.  Scattered hemangiomata were seen in the vertebral bodies.  The assessment was herniated disc (L4-L5) right; lumbar radiculopathy; lumbar intervertebral disc degeneration; and chronic pain; facet syndrome.  

The Veteran was seen for an individual VA therapy session in October 2011.  He reported recurrent suicidal ideation, but denied plan/intent at present.  A suicidal safety plan was initiated.

A letter from the Veteran's VA clinical psychologist, Dr. S.M., dated in October 2011 reports that his symptoms of PTSD are severe with no significant improvement with treatment; that he was also diagnosed with depression, not otherwise specified; and that he had significant worsening of symptoms resulting in total occupational and social impairment.  Dr. M. reported that the Veteran continued to report severe sleep disturbance (going for two to three days with no sleep; when he does sleep, sleep is interrupted by disturbing dreams of combat); reported feeling depressed and lacking interest and enjoyment in his usual activities; reported feeling distant and cut off from people as well as feeling emotionally numb; and reported being hypervigilant, irritable and easily startled.  Dr. M. reported that the Veteran demonstrated impaired judgment and impulsive behavior.  He had recently done "surveillance" on his wife by finding a location where he could monitor the parking lot of her place of employment and using binoculars to be sure her car was parked in the lot.  He also recorded himself on his smart phone prior to confronting his wife's co-worker and when he played the video for Dr. M., the Veteran had recorded the date and location as if on a mission.  He had also left a message for his sons in case he "died" that day.  He was in no way physically threatening his wife's co-worker, but was concerned that the meeting could end with his being killed.  Another example of impulsivity and poor judgment was when arguing with his wife on September 28, 2011, the Veteran became extremely agitated and smashed his cane on the bathroom counter, shattering the counter, then threw his cane, which hit the ceiling of the bathroom causing a large dent and bending the cane, requiring its replacement.  Dr. M. reported that the Veteran's symptoms of PTSD had put a significant strain on his relationship with his wife and two teenage sons.  Dr. M. also reported that the Veteran indicated his mood was very depressed; that he felt hopeless about the future, stating "there is no future that I want to be in;" that he admitted to daily thoughts of suicide, though he denied intent or plan at that time; that he had given away personal belongings and made sure his financial matters were up to date; that his relationship with his sons and his religious beliefs are the only protective factors against making a suicide attempt that the Veteran could identify; that his appetite was decreased and he had lost about 15 pounds in the last two to three months; that he had very limited, if any, contact with his friends and had stated "I don't want to see friends when I am like this. I don't want to explain;" and that his VA providers were his primary support system at the present time.  Dr. M. concluded by stating that the Veteran's symptoms of PTSD were further complicated by co-morbid, service-connected conditions, including cognitive deficiencies and tinnitus secondary to TBI and chronic pain issues secondary to back injury.  It was not possible to differentiate which symptoms were related specifically to PTSD and which were related to depression, not otherwise specified, due to the overlap of symptoms.  Dr. M. indicated that based on the history of the Veteran's conditions, the depression appeared secondary to PTSD and that his PTSD and depression symptoms were causing total social and occupational impairment.  

A letter from the Veteran's treating physician at the VA poly-trauma/rehab services clinic, Dr. S.K., dated in October 2011 reports, in pertinent part, the Veteran had resulting TBI, chronic back pain, depression, and PTSD as a result of the in-service blast injury.  He also had short-term memory problems, poor concentration, problems with easy distractibility, and difficulty with multitasking.  In addition to chronic back pain, the Veteran also had chronic leg pain.  In July 2011, his back pain worsened significantly to the point where it was difficult for him to walk secondary to right leg numbness and weakness.  Subsequent MRI imaging revealed that a disc fragment was sitting on the lumbar nerve root.  The Veteran had been treated with physical therapy and nerve blocks and was scheduled for back surgery on October 19, 2011.  

An October 2011 VA psychiatric progress notes that the Veteran was "doing fine."  He reported he still did not have the answers he wants regarding his marital relationship but thought he should wait at least a week before bringing it up to his wife.  He had been talking to a relationship coach and reported his wife refused to get any help.  Mental status examination revealed fair grooming and hygiene.  Demeanor was cooperative and speech was of regular rate and rhythm.  The Veteran reported mood as "doing fine" and affect was depressed.  Thought process was linear.  The Veteran reported having suicidal ideation the week prior, but did a suicide safety plan which he was following and had not been suicidal since following that plan.  He denied current suicidal and homicidal ideation, intent and plan.  He also denied auditory and visual hallucinations and delusions.  Insight and judgment were fair and the Veteran was alert and oriented grossly.  The assessment was PTSD; postconcussion syndrome; depression; insomnia; and anxiety disorder, not otherwise specified.  

An October 2011 VA polytrauma note documents that the he attended and participated in kayaking and swimming, at which time he presented with flat affect congruent with his mood.  He remained disconnected the majority of the session and presented with decreased social interactions and decreased willingness to converse.  

An October 2011 VA polytrauma psych note documents that the Veteran reported feeling more depressed and hopeless with "no future I want to be in."  An increase in situational stressors was noted, to include with his son and that his relationship with his wife remained stressful.  The Veteran described an argument the week prior when he smashed a can on the bathroom counter, shattering counter, and also throwing his cane.  He indicated that he did not threated or harm his wife.  

The Veteran was seen at Walter Reed in October 2011 with chief complaint of right lower extremity pain.  He reported mild to moderate lower back pain but being more bothered by the right leg pain.  He experienced paresthesias that go down the lateral thigh to the anterior leg.  He denied bowel/bladder symptoms.  Physical examination revealed that straight leg testing of the right leg was positive, and negative on the left.  Crossed straight leg raising test was negative bilaterally.  A Patrick-Fabere test was negative at the right and left sides of the sacroiliac joints.  Neurological testing revealed no decreased response to tactile stimulation of the entire right and left legs and no decreased response to stimulation by vibration on either leg/foot.  Motor strength examination was normal and reflex testing was normal.  An MRI was performed and showed foraminal herniated nucleus pulposus at right L4/5 that causes impingement of right L4 nerve root; and lumbar spondylosis.  The assessment was lumbar spondylosis and herniated disc (L4-L5).  
A subsequent October 2011 record from Walter Reed indicates that the Veteran was seen for preoperative exam with assessments of herniated disc (L4-L5) right; lumbago and right lumbar radiculopathy.  He was scheduled for a nerve root decompression L4-5 right on October 19, 2011.  The Veteran complained of pain the back and right lower extremity, increased pain with standing and ambulation, and a current pain level of seven out of 10.  

The Veteran underwent surgery (nerve root decompression L4-5, right) at Walter Reed on October 26, 2011.  He was admitted on the day of surgery with a diagnosis of herniated disc, L4-5 right and chief complaint of low back pain and bilateral radiculopathy.  He reported that his left leg pain had resolved since ESI treatment, but his right leg had worsened with associated weakness, most noticeable when walking down the stairs/hill.  The Veteran had been using a cane since July 2011 and denied any bladder or bowel dysfunctions.  Lumbar spine MRI was consistent with a far lateral disc protrusion at L4-5 on right with predominant L4 root impingement and possible L5 impingement as well, DDD at L5-S1.  It was reported that the Veteran had failed conservative management.  Physical examination on admission revealed that the Veteran was ambulating well in no acute distress.  Gait revealed abnormal tandem gait and abnormal toe walk on the right, but normal heel walk and balance.  Muscle tone on the bilateral lower limbs was normal.  Lumbar flexion, lumbar extension, lateral rotation, and lateral bend were all reported as normal without any measurements provided, though pain was elicited.  Straight leg raise was positive on the right.  Muscle strength was normal for all but slightly decreased on the right quadriceps, right EHL and right gastrocnemius.  Sensory examination revealed decreased response along L4 and L5 dermatomes on the right.  Patellar reflexes were absent on the right and 2+ on the bilateral ankles.  The Veteran was discharged on October 27, 2011, with specific instructions and was advised to begin physical therapy in a few weeks.  The discharge diagnosis was herniated disc L4-5 right.  

A November 2011 VA patient record flag notes that the Veteran reported relationship problems that had caused suicidal thoughts and anxiety.  He agreed to have additional support by the suicide prevention team.  He reported that he really wanted his relationship to work.  A November 2011 VA polytrauma note documents that the Veteran appeared shaky and to have lost more weight.  He continued to have difficulty sleeping due to stress in the home.  

A November 2011 VA neurology outpatient consult note documents that the Veteran was seen for a one week post-operative follow up after undergoing a right L4-5 nerve root decompression on October 26, 2011, at Walter Reed for a L4-5 herniated disc.  The Veteran reported that his right leg pain was resolved but that numbness persisted to his anterolateral thigh and that some weakness in his whole right leg persisted.  He reported some achy low back pain associated with surgery at a level four but denied changes in bowel or bladder control.  Physical examination revealed no tilt, no scoliosis, and hips appeared level.  The lumbar spinous processes were nontender, paraspinous muscles were nontender without spasm, and the greater trochanters, sciaticas, and ischial tuberosities were nontender.  Range of motion testing revealed decreased lumbar flexion, extension, rotation and lateral bending, with pain elicited, but no actual measurements were provided.  Left lower extremity strength was normal on testing and deep tendon reflexes were 2+ for patellar (L4) and ankle (S1).  Straight leg testing did not produce pain.  Gait was unimpeded, slow, and wide without toe drop.  The Veteran walked with the assistance of a cane.  Tandem, heel and toe walking was intact.  Patrick's maneuver did not produce pain.

A November 2011 VA polytrauma psych note documents that the Veteran reported his relationship with his wife seemed better at times, but there was continued conflict at times.  The Veteran admitted to having problems with trust and checking up on his wife, which she resented.  He also reported decreased appetite.  

A November 2011 VA physical therapy initial evaluation note documented the Veteran's back pain and radicular symptoms to the right lower extremity.  The Veteran noted that his pre-surgical symptoms were gone but he was very hesitant to move in all direction.  An aggravating factor was all movement.  An easing factor was rest.  Physical examination revealed decreased lumbar lordosis.  Active range of motion testing revealed 40 degrees of flexion, 10 degrees of extension; and 20 degrees of bilateral rotation and bilateral side bending.  Sensation was intact to light touch in the bilateral lower extremity.  Pain was at a level four out of 10.  Gait was within normal limits.  Straight leg testing was negative.  

The Veteran underwent a VA examination on November 1, 2011, which, in pertinent part, examined his service-connected spine, left lower extremity and residuals of TBI, to include slow speech, disabilities.  In regards to his spine condition, the Veteran reported that he could walk without limitation, an average of 10 miles in 30 minutes; that he had experienced falls due to the spine condition; and that he had stiffness, fatigue, spasms, decreased motion and numbness due to the spine condition.  He denied paresthesia, bowel problems, and bladder problems, but indicated he had weakness of the spine and leg and erectile dysfunction.  The Veteran reported pain, which was located on the L4, L5 and right leg, which occurred constantly and traveled to the right leg and foot.  The level of pain was reported as severe and could be exacerbated by physical activity and stress.  The pain would come spontaneously and was relieved by rest.  At the time of pain, the Veteran experienced functional impairment in the form of weakness in the right leg, inability to stand or sit for longer than 10 minutes, and inability to commute to work.  Treatment included nerve blocks and pain management.  The Veteran reported undergoing surgery (nerve blocks) in April 2010 and July 2011.  He described the residuals of shooting pain and weakness.  Over the past 12 months, the Veteran reported the following incapacitating episodes: July 12-November 1, 2011, for over 90 days.  The physician who recommended bed rest was Dr. Z.  In regards to his left lower extremity condition, the Veteran reported limitation in walking, and that on average, he could walk 500 yards in one hour.  He had experienced falls, stiffness, fatigue, spasms, numbness and weakness of the spine, leg and foot.  He denied experiencing decreased motion, paresthesia, bowel problems, erectile dysfunction, and bladder problems.  Pain was located on the L5 and occurred daily lasting for one hour.  The pain traveled to the top of the foot and was reportedly severe.  It could be exacerbated by physical activity and stress and came spontaneously.  It was relieved by rest and the Veteran was able to function with medication at the time of pain.  He denied functional impairment or limitation of motion.  The condition had not resulted in any incapacitation over the last 12 months.  In regards to the residuals of TBI, the Veteran reported that he experienced confusion, slowness of thought, problems with attention/concentration, difficulty understanding directions, problems with reading such as inability to track the line being read, problems with anxiety (inability to retain information), depression and thoughts of suicide, occasional problems with memory, fatigue, hypersensitivity to light (inability to study in light), hypersensitivity to sound (avoiding noise), irritability, inability to relax or sleep, hypervigilance, difficulty in finding the right words to say (expressing himself), difficulty pronouncing words (articulation), and difficulty with speech and word recognition.  The Veteran denied mood swings, heat intolerance, abnormal sweating, trouble sleeping, and difficulty with swallowing.  The Veteran also reported dizziness occurring three times a day and vertigo occurring three times a day.  He also reported a minor seizure disorder.  A typical attack was described as during sleep, evoked by stress, and alleviated on its own.  Over the last two years, the Veteran reported two attacks in total, averaging one each year.  The Veteran also reported impotency.  

Physical examination at the time of the VA examination in November 2011 revealed, in pertinent part, a scar precisely located status post lumbar surgery.  It was linear and superficial and measured six centimeters by one centimeter.  The scar was not painful, there was no skin breakdown or underlying tissue damage, and there was inflammation, edema, keloid formation or disfigurement.  The scar did not limit motion or function.  The Veteran walked with a limp due to recent lumbar surgery and was also described as unsteady.  The Veteran had no difficulty with weight bearing, balancing or ambulation (though he required a cane for ambulation).  Physical examination of the thoracolumbar spine revealed no evidence of radiating pain or muscle spasm, but there was tenderness and guarding of movement, during which there was no preservation of spinal contour, which did not produce an abnormal gait.  Examination revealed weakness, but muscle tone and musculature was normal.  Straight leg testing was positive on both sides, as was Lasegue's sign, but there was no limb atrophy or ankylosis.  Range of motion of the thoracolumbar spine revealed flexion to 20 degrees, with pain at 20 degrees, and extension, bilateral lateral flexion, and bilateral rotation all to 5 degrees, with pain at 5 degrees.  The Veteran was able to accomplish repetitive motion and there was no additional limitation of motion on repetition.  There was also no additional limitation of joint function due to pain, fatigue, weakness, lack or endurance or incoordination after repetitive use.  Neurological examination revealed that motor function was within normal limits.  The right sensory function for the sciatic nerve was decreased on pinprick.  Sensory examination on the left was normal and reflex testing was bilaterally normal.  There was no indication of peripheral nerve involvement on examination.  Sensory function of the lumbar spine was impaired on pinprick in the sacral spine.  There was no lumbosacral motor weakness.  Sensory deficits were noted at the right anterior lower thigh and right inner knee (L3); right lateral thigh, right front leg and right medial leg (L4); right lateral leg (L5 and S1).  There were signs of lumbar IVDS but it did not cause any bowel or bladder dysfunction.  The autonomic nervous system was within normal limits with no hyperhidrosis, heat intolerance or orthostatic hypotension.  The examiner reported that the lumbar spine x-ray showed degenerative arthritis.  The Veteran was diagnosed with IVDS without degenerative joint disease of the lumbar spine and sciatic nerve deficiency, left leg, due to IVDS of the lumbar spine.  In regards to the slow speech due to TBI, the examiner indicated that there was no diagnosis because there was no pathology to render a diagnosis.  In an addendum, the examiner reported that the Veteran's erectile dysfunction was secondary to his lumbar IVDS.  

The Veteran also underwent a VA psychiatric examination in November 2011, at which time he reported recurrent nightmares causing disruptive sleep patterns; daily intrusive memories that stir up feelings of sadness, anxiety, and some anger; survival guilt; depression; frequent moodiness and irritability; emotional detachment, isolation and being withdrawn; hypervigilance; being easily startled (by unexpected noises and movements); difficulty trusting and getting close to people; intermittent suicidal ideation; and problems with memory, executive functioning, focus and concentration as a result of his TBI.  The Veteran reported that he recently found out his wife was having an extramarital affair, which had added to his feelings of depression and emotional isolation.  There had also been significant financial stress as the Veteran spent excessively in 2007 and 2008, which got the family $50,000 in debt.  The Veteran denied problems managing his money over the past three years.  The Veteran also reported decreased appetite and significant weight loss, but denied any plan or intent to hurt or try and kill himself.  The Veteran reported that he had been married for 25 years to his wife and there was significant conflict and emotional estrangement secondary to his wife's extramarital affair.  The Veteran had two sons, ages 18 and 15.  The older son was in college.  The Veteran denied any history of drug abuse, reported drinking up to six beers in an evening at times, denied any alcohol related problems, and denied receiving any DUIs.  He also denied a history of legal problems.  The Veteran reported that he liked to target shoot, but had lost interest recently.  Mental status examination revealed that the Veteran was alert, calm, pleasant and withdrawn.  Speech was of normal rate and coherent.  Affect was constricted in range and depressed.  Mood was also depressed.  The Veteran was tearful at times throughout the interview.  He reported intermittent suicidal ideation but no plan or intent to hurt or kill himself.  There was no homicidal ideation and no delusions or hallucinations.  Insight and judgment were adequate overall, but short term memory was severely impaired in that the Veteran recalled three out of three words initially, but zero out of three words at five minutes.  The Veteran was also not able to concentrate to attempt serial sevens after initially giving the first correct answer of 93.  The Veteran was able to recall presidents correctly back through President Reagan in correct order.  Axis I diagnoses of PTSD and cognitive disorder, not otherwise specified, were provided.  A GAF of 50 was assigned for PTSD and a GAF of 45 was assigned for cognitive disorder, not otherwise specified, secondary to TBI.  The examiner indicated that the Veteran had severe social and occupational dysfunction secondary to his PTSD with significant depression and irritability, emotional detachment and isolation and withdrawal, significant problems sleeping at night with nightmares and problems focusing and concentrating secondary to intrusive memories that can be overwhelming to the Veteran, and prominent survival guilt and depression.  The examiner noted that the cognitive disorder also caused very severe social and occupational dysfunction due to prominent problems with short term memory and executive functioning, problems focusing and concentrating and getting tasks done.  The examiner believed the Veteran was at acute disk for self-harm or suicide.  The Veteran's prognosis was poor.  

A December 2011 VA neurology outpatient consult reveals that the Veteran was seen for post-operative follow-up.  He had some level three achy low back pain associated with surgery, which was worse with standing greater than 15 minutes.  The Veteran denied any changes in bowel or bladder control.  Physical examination revealed no tilt, no scoliosis, and the hips appeared level.  The lumbar spinous processes were nontender, the paraspinous muscles were nontender without spasm, and the greater trochanters, sciaticas, and ischial tuberosities were nontender.  Range of motion testing revealed decreased lumbar flexion, extension, rotation and lateral bending, with mild pain elicited, but no actual measurements were provided.  Motor strength was normal in the lower extremities and deep tendon reflexes were 2+ bilaterally.  Straight leg raises did not produce pain.  Gait was unimpeded without toe drop.  Tandem, heel and toe walking were intact.  Patrick's maneuver did not produce pain.

A January 2012 x-ray of the lumbar spine documented evidence of arthritic change with some degenerative changes of the lower lumbar spine with narrowing of the disc space and some mild foraminal narrowing.  There was no compression or fracture.  T12-L1 showed Schmorl's node with some degenerative changes, disc space narrowing.  There is no compression or fracture.  The impression was degenerative changes.

A January 2012 VA rehab med outpatient note documents that the Veteran's back was tender in the right lower lumbar area and along the iliac crest.  Range of motion was painful, but no actual measurements were provided.  Strength was slightly decreased on the right side.  Deep tendon reflexes were 1+ and improved.  The Veteran was ambulating without a cane.  The impression was lumbar radiculopathy, right leg weakness, status post L4-5 nerve root compression, and chronic low back pain with facet arthropathy and degenerative disc.

A January 2012 VA neurology outpatient consult note documents that the Veteran was seen for post-operative follow up (right L4-5 nerve root decompression).  He denied any changes in bowel or bladder control.  Physical examination revealed no tilt, no scoliosis, and the hips appeared level.  The lumbar spinous processes were nontender, the paraspinous muscles were nontender without spasm, and the greater trochanters, sciaticas, and ischial tuberosities were nontender.  Range of motion testing revealed decreased lumbar flexion, extension, rotation and lateral bending, with mild pain elicited, but no actual measurements were provided.  Sensory examination revealed decreased sensation to light touch and sharp stimuli at the right anterolateral thigh and lateral right foot.  Deep tendon reflexes were 2+ bilaterally.  Straight leg raises did not produce pain.  Gait was unimpeded without toe drop.  Tandem, heel and toe walking were intact.  Patrick's maneuver did not produce pain.

A January 2012 VA mental health note documents that the Veteran was not sure what his wife was going to do regarding their marriage.  He was no longer talking to a life coach about this and was dealing with it "hour by hour."  The Veteran reported getting drunk before Christmas, which made him depressed, but he felt hopeless and overwhelmed by all going on with family issues.  The Veteran also reported he had not been sleeping well with stress.  He reportedly took out his guns, spread plastic out if there would be a mess, and wrote letters to his sons.  His wife heard him and came in and took the guns away.  The guns were now in his safe.  The Veteran reported he was glad he did not complete the suicide and reported his kids were his deterrent.  He denied suicidal ideation since and being suicidal now.  Mental status examination revealed no homicidal ideation, no suicidal ideation, and no hallucinations.  The Veteran appeared depressed and affect was congruent to mood.  Grooming and hygiene were fair, the Veteran was alert and grossly oriented, and eye contact was good.   Motor function was within normal limits.  Speech was of regular rate, rhythm and volume.  Thought processes were linear.  The Veteran denied perceptual disturbances and hallucinations.  Insight and judgment were fair. The diagnoses were PTSD; postconcussion syndrome; depression; insomnia, and anxiety disorder, not otherwise specified.  A GAF score of 51 was assigned.  

A February 2012 VA polytrauma psych note documents that the Veteran reported his mood was stable and he had been "less snoopy" regarding his wife's phone calls and emails.  He was also walking away from arguments with his wife rather than engaging or becoming defensive.  The Veteran also reported reaching out to individuals identified as supportive. 

A March 2012 VA polytrauma psych note documents that the session focused on the Veteran's relationship with his wife.  The Veteran said he became very upset on Friday and Sunday evening due to negative thoughts related to being able to trust his wife.  He said he did not use his plan to call a friend until this morning, but acknowledged that he felt better when he did this and will try to practice this more regularly in the future.  

A March 2012 VA polytrauma psych note documents that the Veteran discussed multiple stressors, including his relationship with his wife and wanting her to make a decision about whether she wishes to stay married and work on their relationship.  The Veteran also discussed his concern for his children and their well-being.  Another March 2012 polytrauma psych note dated on the same day revealed the following: the Veteran discussed his ongoing conflicts with his wife for the last seven months.  He reported that most recently, his wife requested space from him to consider whether she will stay with the Veteran or seek a divorce.  The Veteran discussed difficulty waiting for her decision, which had led to increased symptoms of anger and anxiety. 

A March 2012 VA mental health note documents that mental status examination revealed fair grooming and hygiene.  The Veteran was cooperative and alert and grossly oriented.  Eye contact was good and motor function was within normal limits.  Mood was depressed and affect was congruent to mood, but relatively brighter.  Speech was of regular rate, rhythm and volume.  Thought processes were linear.  The Veteran denied delusions, perceptual disturbances, and hallucinations.  Insight and judgment were fair.  The Veteran reported fleeting suicidal ideation, but no suicidal intent or plan due to his kids.   The diagnoses were PTSD; postconcussion syndrome; depression; insomnia, and anxiety disorder, not otherwise specified.  

An April 2012 VA polytrauma psych note documents that the Veteran reported his sleep medication had been discontinued at his last appointment and he was dreading the next time he will have a disturbing dream because he wakes up in a panic.  He reported that his dreams are often about the explosion in which he was injured.  The Veteran said that he is "stuck in this time."  The Veteran reported how he had changed since his injury (poor memory, unable to multitask, does not volunteer, headaches incapacitate him) and how he sees himself as worthless.  

An April 2012 VA OEF/OIF/OND note documents that the Veteran was casually dressed with pleasant demeanor.  The thoughts expressed were delayed, but goal directed.  The Veteran reported continued but diminishing low mood.  Suicidal ideation persisted but the Veteran denied intent to act.  He admitted to drinking two to three shots of whiskey nightly for the past two weeks in order to get to sleep, which averaged at one to two hour intervals.  The Veteran's home life was reportedly difficult.  

An April 2012 VA mental health note documents that mental status examination revealed the Veteran appeared with fair grooming and hygiene, was cooperative, and was alert and grossly oriented.  Eye contact was good, motor function was within normal limits, mood was depressed, and affect was mood congruent, but relatively brighter.  Speech was of regular rate, rhythm and volume.  Thought processes were linear and the Veteran denied delusions and hallucinations, though it was noted that he was hypervigilant.  Insight was fair and judgment was impaired regarding alcohol.  The Veteran reported fleeting suicidal ideation, but no suicidal intent or plan due to his kids (he immediately thinks of them).  The diagnoses were PTSD; post-concussion syndrome; depression; insomnia; and anxiety disorder, not otherwise specified.  

An April 2012 VA mental health note documents that the Veteran reported the Easter holiday weekend was difficult because he goes to his in-law's house and his in-laws tend to ask him how he is doing, which he does not want to talk about, and he feels he and his wife have to outwardly act like everything is ok.  His strained marital relationship, and the negative consequences this environment has on his sons, was discussed, as were the Veteran's fears if he and his wife divorced.  

A May 2012 VA polytrauma psych note documents that the Veteran reported going to Philadelphia this past weekend with his wife and younger son for his son's hockey game.  Although he felt as if his wife was doing things to 'push his buttons' and he wanted to 'explode', he did not have any outbursts.  He reported that part of the reason he kept himself under control was that he does not want to have a "bad report" when he goes to group or these individual sessions and does not want to let people down. 

Another May 2012 VA polytrauma psych note documents that the Veteran had been working on completing paperwork to officially resign from his most recent contracting job.  Some of the paperwork/phone calls had been confusing, but he did not want to ask his wife for help as he feels she already thinks he cannot handle tasks on his own.  The Veteran described his recent mood as "angry."

Another May 2012 VA polytrauma psych note documented that the Veteran was in the process of being cleared to volunteer for a Wounded Warriors program.  He reported being surprised that so many Veterans still "fall through the cracks" and would like to help them get the support/treatment they need.  The Veteran also reported that he was planning to officially resign from the defense contract job that he was doing up until July 2011 and will send a letter in next week.  The Veteran noted that he would be attending his wife's niece's wedding this weekend but is not looking forward to it because he said that his wife and other family members do not get along.  

Another May 2012 VA polytrauma psych note documented that the Veteran said he still planned on sending a letter to his employer in order to resign from his previous contract job.  He noted "I wish I could just ask for a leave of absence."  The Veteran attended his wife's niece's wedding over the weekend.  He said it went better than he anticipated and that he did not get into any arguments.  

A June 2012 VA polytrauma psych note documents that the Veteran's paperwork has cleared for him to volunteer to help other recent returning Veterans with paperwork and the medical board process.  He indicated he had wanted to volunteer at Fort Belvoir, but he is being asked to go to Bethesda.  The ongoing difficulties in the relationship with his wife and continued unhelpful interactions were discussed.  The Veteran admitted that their relationship was unhealthy but that he feared separating/divorce would not help.  The Veteran said focusing on their relationship takes him away from other issues, such as symptoms of PTSD.  

A July 2012 VA mental health note documents that mental status examination revealed the Veteran was fairly groomed and engageable with grossly intact cognitive functioning.  Eye contact was fair; motor function was spontaneous; mood was "good" and affect was broad and appropriate to content.  Speech was fluid and thought processes were linear.  The Veteran denied delusions, first rank symptoms, and perceptual disturbances.  Insight and judgment were fair and the Veteran denied suicidal ideation, intent, and plan.  A GAF score of 60 was assigned.  

A July 2012 VA polytrauma psych note documents that the Veteran provided an update about his relationship with his wife.  He said that he felt he has seen some small, slow progress, but then reported that he and wife had an argument when the topic of their marriage came up last week.  The Veteran also reported that he had been trying to do things for himself, such as volunteer one day per week, work around the house, and spend time with his sons.  He and family were going on vacation to Florida at the end of July.  

An August 2012 VA mental health note documents that the Veteran reported that his trip to Florida was a good trip.  He indicated that just before the trip, he decided that he needed to "let things go" more than he had been (e.g., with his oldest son and especially with his wife) as he did not want to ruin the vacation.  He had continued to do this and felt that it had helped decrease his stress.  The Veteran admitted that he did feel somewhat lonely, especially at night when his sons are going about their business and his wife is asleep.

A September 2012 VA mental health note documents that mental status examination revealed the Veteran had fair grooming and hygiene; was cooperative, alert and grossly oriented, had good eye contact and that motor function was within normal limits.  When asked about his mood, the Veteran reported that "it's been a hard week.  Affect was congruent to mood, but the Veteran was noted to smile appropriately.  Speech was of regular rate, rhythm and volume; thought processes were linear; and the Veteran denied delusions and hallucinations.  It was noted that the Veteran endorsed hypervigilance.  Insight was fair and judgment was noted to be impaired regarding alcohol use, but adequate for safety.  The Veteran denied any current or recent suicidal ideation, intent or plan.  The diagnoses were PTSD; post-concussion syndrome; depression; insomnia; and anxiety disorder, not otherwise specified.  A GAF score of 60 was assigned.

A November 2012 VA polytrauma psych note documented that the Veteran had not been seen for an individual session since August and that he had been encouraged to return to therapy as he has been reporting increased depression and anger and decreased motivation.  He discussed that he had been angry because he felt he had no control and is no longer a leader in the military.  The Veteran also believed that he made things more difficult by not accepting his injury and limitations.  It was noted that while the Veteran can verbalize his limitations, his behaviors do not always reflect this.  He reported that he would like to resume individual therapy every other week, but that he would be out of the country with his family from mid-December until the new year.  

A December 2012 VA polytrauma psych note documents that the Veteran and his family planned to go to Austria for the holidays.  When asked if he had any concerns with the trip, the Veteran said he had tried to plan for this by renting a large van and two apartments so he and his family would not be cramped.  When asked what his plan was if he felt overly stressed or in crisis, the Veteran said he did not have a plan because he anticipated everything would be ok.  The Veteran was encouraged to have contact people in mind (other than wife), and was able to come up with two friends who he would call. 

A November 2012 VA physical medicine rehab outpatient note and a December 2012 VA physical therapy outpatient note document normal strength, deep tendon reflexes and sensation in the left lower extremity.

VA treatment records document that the Veteran went to Austria over Christmas in 2012 but suffered concussion while skiing there.  Following his trip, the Veteran reported that he was almost at baseline, but had weakness on the right side and word finding difficulty.  

A February 2013 MRI of the lumbar spine contains an impression of questionable post-surgical changes of right hemi-laminectomy at L4-L5 (correlation with prior surgical history may be beneficial); loss of fat signal within the right lateral epidural space (may represent scar tissue); loss of fat within the right neural foramen (may represent scar tissue versus disc extrusion/sequestration); moderate neural foraminal stenosis on the right; and no significant spinal canal stenosis. 

An April 2013 VA pain procedure note documents that the Veteran was seen with  chief complaint of low back pain across the lumbosacral area with radiation to right buttock, anterior right thigh, medial lower extremity, and right foot.  Occasionally, his right leg would feel weak with a tendency to fall.  Aggravating factors included prolonged walking, standing and sitting.  Alleviating factors included moving around, heat, and medication.  It was noted that the Veteran had undergone a right L4-5 discectomy in 2011 and that a 2013 MRI of the lumbar spine showed question post-surgical changes of right hemi-laminectomy; ill-defined soft tissue within the lateral epidural space may represent scar tissue; facet arthrosis and mild concentric disc bulge; loss of the fat within the right lateral recess; a right foraminal disc extrusion/sequestration versus granulation tissue; no significant spinal canal stenosis; moderate right neural foraminal stenosis; and no significant left neural foraminal stenosis at the L4-L5 level; at the L5-S1 level, there was bilateral facet arthrosis but no significant spinal canal or neural foraminal stenosis.  Physical examination in April 2013 revealed that strength testing showed right sided weakness.  Deep tendon reflexes were normal and sensory testing revealed numbness in the medial right lower extremity.  The Veteran had steady stance and gait and straight leg testing was bilaterally negative.  The assessment was right L4 lumbar radiculopathy; right foraminal disc extrusion/sequestration versus granulation tissue.

An April 2013 VA polytrauma psych note indicated that the Veteran arrived late and began discussing the Veterans that he has been volunteering to help.  It was noted that he tended to provide an update on others but not what is going on with himself.  The Veteran laughed and seemed to acknowledge this was true.  He went on to say that he was not sleeping well due to pain and increased frequency of nightmares, and that he was easily irritated.  He also expressed frustration about feeling that his wife does not take his cognitive difficulties into account when communicating with him, resulting in him feeling angry, overwhelmed, and as though he wants to "run away."  The Veteran did note a recent positive event; he went to a wedding where he did not know anyone and was able to successfully manage interacting with people without discussing his military career/retirement. 

A May 2013 VA pain procedure note documents that the Veteran underwent a selective nerve root block/Transforaminal epidural steroid injection, right L4.  

A May 2013 VA physical medicine rehab outpatient note documents that since his last visit, the Veteran continued to have back pain at a level seven-eight out of ten, as well as weakness in the right leg.  He reported that, sometimes, it felt like his leg gives out.  He also had pain radiating to the right leg.  The Veteran reportedly underwent a selective nerve root block without pain relief.  He reportedly discussed this with a pain physician and will be scheduled for second injection.  If that does not work, he will see a neurosurgeon.  The Veteran also indicated that he continued with physical therapy.  Physical examination revealed normal strength in the left lower leg and with right hip flexion.  Strength was slightly decreased with right knee extension and hamstrings.  Deep tendon reflexes were 1+ at the right knee and 2+ on left side.  Sensation was decreased in the right thigh and calf area.  Gait was stable.  The impression was chronic low back pain with right leg weakness, lumbar radiculopathy, and foraminal stenosis with scar tissue at L4 to L5 level.

A May 2013 VA mental health note documents that the Veteran reported doing ok and keeping busy with training his service dog, though he was initially overwhelmed by all the training requirements.  He indicated that he got depressed due to lack of mobility and not being able to do what he used to, that he needed another back surgery.  Mental status examination revealed that he was casually dressed and cooperative with good hygiene, good eye contact, and normal psychomotor activity.  Speech was of normal rate and volume.  Thought process logical and goal directed.  When asked about his mood, the Veteran reported "kind of feeling down, lot of frustration, finds everything hard to do that he used to be able to do, between pain and lack of mobility, depresses him, and another back surgery."  He had full range affect and denied auditory/visual hallucinations and paranoia.  The Veteran indicated he had some hopelessness, helplessness, worthlessness and guilt and that he felt frustrated he cannot serve in the military anymore.  It was also noted that he did some volunteer work helping other Veterans.  His interests were limited, appetite was ok, and energy was lacking.  The Veteran indicated that he was not sleeping well, and was only sleeping two hours during the week; that he stayed up on the weekend and tried to go back to sleep, but woke up after an hour or so.  The Veteran denied manic symptoms and any suicidal or homicidal ideation, plan or intent.  Judgement/insight were good and the Veteran was alert and oriented times three.  Axis I diagnoses of PTSD; history of TBI postconcussion syndrome; depression; insomnia; and anxiety disorder, not otherwise specified, were made.  A GAF score of 52 was assigned.

A May 2013 VA speech pathology consult reveals that oromotor examination revealed mandibular, labial, and lingual range of motion and strength were within full limits.  Palatal elevation was present bilaterally during phonation.  Speech examination revealed respiration, phonation, articulation, resonance and prosody were within full limits.  The impressions were moderate-severe cognitive-communication deficits due to low scores on memory, attention, reading comprehension and listening comprehension testing.  There was no need for medical follow up for dysfluency/speech disorder.  

The Veteran was seen at Walter Reed in June 2013 with complaint of low back and right leg pain.  It was noted that a thoracolumbar intervertebral fusion (TLIF) at L4-5 on the right for his lateral and foraminal disk herniation at L4-5 was discussed and that he had undergone paraspinal steroid injection at VA without symptom improvement.  The Veteran reported pain at a level eight out of 10 on a daily basis on average.  Physical examination revealed that straight leg raising test of the right leg was positive at 30 degrees of elevation.  The lumbosacral spine demonstrated full range of motion decreased to 60 percent for normal, but no actual measurements were provided.  Straight leg raising test of the left leg was also negative.  A crossed straight leg raising test of both legs was negative.  A Patrick-Fabere test was negative at the right and left sides of the sacroiliac joints.  Neurological examination revealed decreased response to tactile stimulation of the entire right leg right L4 dermatomal decrease to all modalities on the inside of the calf.  There was no decreased response to tactile stimulation of the entire left leg and no decreased response to stimulation by vibration on either leg/foot.  Motor examination was normal, as was heel and toe walking.  Reflex testing was also normal.  An MRI conducted by VA on February 15, 2013, was reviewed, which showed a right lateral and foraminal disk herniation at L4-5 on the right.  The assessment included herniated disc (L4-L5) and lumbar spondylosis (L4-5 and L5-S1 disk degeneration).  It was noted that the Veteran wished to proceed with surgery in August.  

The Board notes at this juncture that the Veteran failed to report to several VA examinations that had been scheduled in July 2013.  That same month, he indicated that he did not need any more VA examinations for his appeal.  

A July 2013 VA physical medicine rehab outpatient note reveals that the Veteran was seen with chief complaint of back pain.  He continued to have back pain at a level seven out of 10 going up to between a level eight or nine when worse.  The Veteran reported that the week prior had been bad and that he was status post selective nerve block without relief.  He reported mostly weakness in right leg and that coming down was more problem.  It was noted that the Veteran had lost his balance coming down the steps at the hospital that day and that he felt weak and that his leg gives out.  The week prior, he was lying down and started to get up, but felt a sharp pain and collapsed back.  He waited little bit and was able to get up by turning to the side.  Physical examination revealed that the left lower leg had normal strength and that the right leg had decreased strength with hip flexion, knee extension and hamstrings.  Deep tendon reflexes were 1+ at the right knee and 2+ on left.  Sensation was decreased in the right thigh and calf areas.  Gait was stable.  The impression was chronic low back pain with right leg weakness, lumbar radiculopathy, and foraminal stenosis with scar tissue at L4 to L5 level.  

A July 2013 VA neurology outpatient note documents that mental status examination revealed the Veteran was alert and oriented times three, pleasant, cooperative, and able to follow multistep commands.  Language was spontaneous and fluent.  Motor examination revealed normal bulk.  Sensory examination revealed decreased to multiple modalities right L4 and L5.  Deep tendon patellar reflexes were 2+ on the left and absent on right; and 2+ on the bilateral ankle.  Gait was reported as antalgic.  The impression was right L4-5 disk bulge with subarticular extension and foraminal stenosis.  

An August 2013 VA polytrauma note documents that the Veteran reported that he had not felt "post OEF normal" since his seizure.  He stated he felt very rattled and is back to having outbursts, more triggered by his sons' behaviors/activities.  The Veteran also stated he was always tired.  It was noted that he remained involved with other Veterans, which was meaningful for him.  He had started an informal social network for other Veterans in the TBI group.  

An August 2013 VA mental health note documents that the Veteran was last seen in May and came as a walk-in as he needed a letter for surgery medications.  He reported doing ok.  Mental status examination revealed that he was casually dressed and cooperative with good hygiene, good eye contact, and normal psychomotor activity.  Speech was of normal rate and volume.  Thought process was logical and goal directed.  The Veteran reported his mood was of "more anxiety," and he displayed full range affect.  The Veteran denied auditory/visual hallucinations and paranoia.  At times, he had some hopelessness, helplessness, worthlessness and guilt.  He was noted to have some limited interests, to include enjoying helping others.  Appetite was described as ok and energy was described as tired.  The Veteran indicated that he was not sleeping well because he woke up a lot.  He denied manic symptoms and suicidal and homicidal ideation, plan or intent.  Judgement/insight were good and the Veteran was alert and oriented times three.  Axis I diagnoses of PTSD; history of TBI post-concussion syndrome; depression; insomnia; and anxiety disorder, not otherwise specified, were provided.  A GAF score of 52 was assigned.  

The Veteran was admitted at Walter Reed between August 28, 2013, and September 1, 2013, with admitting diagnosis of herniated lumbar disc and discharge diagnoses of lumbar spondylosis, herniated disc L4/L5, and status post L4/L5 TLIF.  The chief complaint was pre-op L4/L5 TLIF.  He first started with low back pain again in December 2012 (after undergoing surgery in 2011) after a skiing accident. The pain was constant at a level seven out of 10.  The Veteran reported shooting pains down his right lateral and anterior thigh, lateral lower leg, and dorsum of the foot.  He also experienced numbness/tingling in this distribution.  He reported a sense of weakness in his right lower extremity.  Symptoms were worsened by stairs and standing.  Medications and physical therapy had provided minimal relief.  The Veteran denied history of foot drop and bowel and/or bladder dysfunction.  The Veteran did have some imbalance occasionally due to TBI and weakness.  Physical examination revealed gait/tandem/heel walk/toe walk was intact; Romberg was negative.  Muscle tone was normal.  Range of motion was decreased due to pain in the lumbar spine, but no actual measurements were provided.  Straight leg raise was negative.  Strength was only slightly decreased and deep tendon reflexes were 2+ but trace at L4.  Sensation and vibratory testing was decreased to light touch and pin prick on the right dorsum/lateral foot, lateral lower leg, lateral and anterior thigh.  An L4/L5 TLIF was performed on August 28, 2013.  

The Veteran was seen for a wound check status post L4/5 TLIF in September 2013 at Walter Reed.  He reported that he still had back pain but it was improving each day.  He denied pain in his legs since the day after surgery and any new neurological symptoms.  He also indicated that his wound was healing well without complication.  

The Veteran was seen for four to six week postoperative follow-up at Walter Reed in September 2013.  He reported that shortly after his last visit, he was trying to grab his dog's leash and his dog pulled him forward quickly, resulting in left lower extremity pain since the incident.  Pain was from the low back to the left posterior thigh.  The Veteran denied numbness and tingling and stated that pain was daily at a level four out of 10 and up to a level nine out of 10 when walking or standing for a prolonged time.  It was also aggravated by long drives.  This low back pain and right lower extremity weakness were both improving.  Physical examination revealed that straight leg raise test of the right leg was negative.  Mild tenderness in the lumbar spine was noted.  Lower extremity weakness was observed in IP and knee extension and flexion, but all others were normal.  Deep tendon reflexes were normal in the ankles and knees.  Two incisions were well-healed without complication.  AP, lateral and spot views of the lumbar spine taken in September 2013 contained an impression of stable post surgical changes at L4-5 posterior spinal fusion with intervertebral disk spacer placement, without evident hardware failure or complication.  

An October 2013 VA mental health note documents that the Veteran reported doing ok.  He had his spinal fusion in August, started physical therapy the week prior, and was keeping busy with nothing except recovering.  Things at home were ok.  The Veteran's mood was down after the surgery, but he hoped the worst had passed.  Mental status examination revealed that the Veteran was casually dressed and cooperative with good hygiene, good eye contact, and normal psychomotor activity.  Speech was of normal rate and volume.  Thought process was logical and goal directed.  Mood was reported as "up and down, down after the surgery," and the Veteran exhibited full range affect.  The Veteran denied auditory/visual hallucinations, paranoia, hopelessness, helplessness, worthlessness or guilt.  He had limited interests, ok appetite, and low energy.  He was not sleeping very well and reported waking up a lot, not being able to sleep on his side, and pain from the surgery.  The Veteran denied manic symptoms and any suicidal or homicidal ideation, plan or intent.  Judgement/insight were good and the Veteran was alert and oriented times three.  A GAF score of 52 was assigned.

An October 2013 VA physical medicine rehab outpatient note documents that the Veteran was seen for a follow up visit following his lumbar fusion and was there to discuss treatment options for pain.  It was noted that the Veteran had started physical therapy the week prior.  He reported that his surgery went well and he felt more strength in his right leg, as well as less pain and less numbness.  The Veteran reported that his back pain was worse at night and made it difficult to sleep.  He also had pain during the day time but was able to manage it by laying in his recliner.  Physical examination revealed normal left lower leg strength.  On the right side, strength was decreased with knee extension, hamstrings, hip flexors, dorsifelxors and EHL.  Deep tendon reflexes were 1+ at the right knee.  The examiner noted improvement as compared to before.  Ankle reflexes were 2+/5 on both sides with the back flat.  The examiner noted healed scars; limited range of motion, though no actual measurements were provided; decreased sensation in the right thigh, though better than before; and decreased sensation in the calf area for both light touch and pinprick.  Gait was stable.  The impression was: 1. Chronic low back with right leg weakness, status post lumbar fusion; 2. Foraminal stenosis with scar tissue at L4 to L5 level; and 3. Residual cognitive problems secondary to head injury.  

VA treatment records document that the Veteran participated in a TBI support group on one occasion in November 2013.  

The Veteran attended chronic pain management classes at Water Reed in November 2013 and December 2013.  He reported fatigue, decreased concentration and sleep disturbance.  The chronic pain the Veteran reported was impacting his overall mood, distress and sleep.  

The Veteran attended a VA polytrauma holiday party in December 2013 and brought a friend.  

A December 2013 VA neurology outpatient note documents that the Veteran was seen for routine post-operative follow up.  He was status post L4/5 TLIF and was managing the low back pain better.  The Veteran reported that driving made it worse and that his pain at the time of the appointment was at a level seven because of drive, but on regular days ranged between a level four and five.  The Veteran managed his pain by restricting activity and following his treatment plan from the Walter Reed pain clinic.  The Veteran reported that his right lower extremity weakness was the same as last visit and he denied any new numbness/tingling.  He was still very satisfied with the surgery because he could do more with his right leg.  It was noted that the Veteran had started physical therapy the month prior and that it was helping.  He was not using a cane anymore except when going to VA or Walter Reed.  The Veteran also denied any new neurological symptoms.  Physical examination revealed that the lumbar spinous processes were nontender and the paraspinous muscles were nontender without spasm.  Range of motion was full in the lumbar spine, but no actual measurements were provided.   Motor examination revealed normal bulk and tone.  Strength was normal but the examiner noted that DF and IP were slightly reduced and that the Veteran had difficulty getting to full dorsiflexion, but once up, he could give 5-/5 effort.  Sensory examination revealed the Veteran still had decreased sensation in the right lower extremity, specifically the lateral and medial lower leg.  Ankle clonus, bilateral straight leg testing, and Romberg testing were negative.  The examiner noted the Veteran's gait was nonataxic and he had normal heel, toe, and tandem gait.  X-ray of lumbar spine contained an impression of patient is transitional lumbosacral anatomy and status post TLIF in the lower lumbar spine with no evidence of hardware complications. 

A December 2013 VA polytrauma note documents that the Veteran was seen for individual therapy after not having been seen since August, though he had been seen during TBI group.  The Veteran discussed changes and adjustments he has been coping with since his back surgery, particularly with regard to needing to ask others for help with both simple activities of daily living (putting socks/shoes on) and more involved tasks (painting, yard work).  The Veteran noted that now he is really is a "disabled Veteran."  He discussed what this meant to him: feeling somewhat helpless, and that he will never return to Afghanistan and will not get "revenge."  The Veteran also discussed, however, that he is trying to focus on taking care of himself and putting his needs first.  He reported attending pain management groups at Walter Reed.  He also noted that although he was still offering to help other Veterans, he was not putting their needs before his/his appointments, and he was not continuously trying to contact these Veterans if they do not show up for their appointment.  The Veteran reported being proud of himself for doing this and being able to have healthy boundaries was reinforced.

VA treatment records document that the Veteran participated in a TBI support group on three occasions in December 2013 and on two occasions in January 2014.  

A January 2014 VA neurology outpatient note documents that the Veteran was status post L4/5 TLIF and was reporting his low back pain was worse.  Pain could range from a level four out of 10 up to a level eight.  It was noted that the Veteran had discontinued physical therapy, but had been swimming.  He reported that the other day while swimming, his right lower extremity went numb.  The numbness comes and goes.  The Veteran also reported a shooting pain in his right lower extremity, which was very rare in his left lower extremity.  The Veteran reported he had been falling and used his cane.  He felt he fell especially when the leg is weak.  Weakness was brought on by too much activity, especially standing.  Physical examination revealed the lumbar spinous processes were nontender and the paraspinous muscles were nontender without spasm.  Range of motion was full in lumbar spine, but no actual measurements were provided.   Motor examination revealed normal bulk and tone.  Strength and deep tendon reflexes were normal.  Sensory examination revealed the Veteran was intact to light touch and sharp stimuli.  Ankle clonus, bilateral straight leg testing, and Romberg testing were negative.  The examiner noted the Veteran's gait was slow and he ambulated with a cane.  A 2014 CT of lumbar spine was reported as containing an impression of redemonstrated postsurgical changes of posterior lateral fusion at L4-L5; mild lucency measuring 1-2 mm about the L4 screws within the pedicles bilaterally, slightly more prominent from the prior exam; the hardware appears intact; intervertebral disc spacer at L4-L5 without significant osseous fusion across the disc space; at L5-S1 there is narrowing of the left lateral recess which impinge upon the descending left S1 nerve root.  The assessment was status post L4/5 TLIF.  Not doing as well, low back pain worsening and new symptoms in the right lower extremity.  CT shows no real fusion as well as lucency in the L4 screws BL.  The Veteran reported that he would be interested in a revision surgery if it was felt he was a candidate. 

A February 2014 VA polytrauma note documents that the Veteran underwent individual psychotherapy after participating in the TBI group.  He continued to discuss his anger and frustration, which was the main topic of group today.  He acknowledged that his anger is likely much higher because of his chronic pain and he attributed 70% of his anger to his pain.  The Veteran indicated that he had rarely used pain medication because he was concerned about becoming addicted.  The Veteran also reported that he had poor sleep (due to pain as well as mental health symptoms), which was contributing to his irritability.  He reported using some relaxation techniques and positive coping strategies such as deep breathing, taking a time-out, and counting to 10.  Certain stressors at home were noted to be decreasing and overall, the Veteran acknowledged his improved ability to manage his anger.  He noted that his biggest concern regarding his anger would be if someone was threatening to his family or friends, which he knew was a more rare occasion.  

VA treatment records document that the Veteran participated in a TBI support group on one occasion in February 2014 and on two occasions in March 2014.  

A March 2014 VA neurology outpatient note documents that sensory examination revealed that the Veteran was intact to pin prick, light touch, vibration, temperature, and proprioception in the left lower extremity but was decreased to pin prick and vibration on the right lower extremity in the L3-L4 distribution.  Romberg was negative.  Gait was mildly antalgic.  The Veteran had some difficulty on three step turn with toe touch and heel, but could do it with encouragement.

A March 2014 VA neurology outpatient note documents that the Veteran was status post L4/5 TLIF.  He reported that the pain in back was manageable and ranged at a level five to eight on a daily basis.  The Veteran reported feeling happy with his surgery because his right lower extremity was better.  He was still undergoing VA physical therapy and was noted to use a cane to walk long distances.  Overall, the Veteran felt his right lower extremity weakness was improving and he denied any new neurological symptoms and any new numbness/tingling.  Physical examination revealed that the lumbar spinous processes were nontender and that the paraspinous muscles were nontender without spasm.  Range of motion in the lumbar spine was reported as full, but no actual measurements were provided.  Motor examination revealed normal bulk and tone.  Strength and deep tendon reflexes were normal.  Sensory examination revealed that the Veteran still had decreased sensation in the right lower extremity, specifically the lateral and medial lower leg.  Ankle clonus, bilateral straight leg, and Romberg testing were negative.  Gait was reportedly nonataxic with normal heel, toe, and tandem gait.  The Veteran was noted to walk with a cane.  A February 2014 x-ray of the lumbar spine was reportedly reviewed, which showed posterior fusion of L4 and L5; mild scoliosis; the height of vertebral bodies and disc spaces were unremarkable except L5-S1 that is narrow; there are few Schmorl nodes; no definite fracture seen.  The examiner noted that the x-ray showed the hardware was still intact and that the x-ray looked normal.  

A March 2014 VA polytrauma note documents that the Veteran volunteered by helping other Veterans and participating in the Wounded Warrior project, and that he occasionally went to the mall with his family.  

A March 2014 VA mental health note documents that the Veteran reported having good days and bad days.  He had been keeping busy with family stresses, but all had resolved.  The Veteran reported that he had had several falls and used a cane if had to do a lot of walking.  Mental status examination revealed that he was casually dressed and cooperative with good hygiene, good eye contact, and normal psychomotor activity.  Speech was of normal rate and volume; thought process was logical and goal directed.  The Veteran reported mood as "tough the last few months, down a lot, thinks it will change, stresses are better" and displayed a full range affect.  The Veteran denied auditory/visual hallucinations and feelings of hopelessness, helplessness, worthlessness, but reported staying vigilant and having some guilt in the back of his mind because he felt responsible for the day of the blast injury.  It was also noted that the Veteran had limited interests, anhedonia, and felt burned out.  He felt things would change and was optimistic.  Appetite was noted to be ok, energy was variable (up and down), and the Veteran had difficulty with sleep pattern as he was tired the next day after having difficulty getting to sleep.  He also reported trouble getting back to sleep, not staying asleep long, and having dreams that woke him up.  He reported snapping at people due to poor sleep.  The Veteran denied manic symptoms and any suicidal or homicidal ideation, plan or intent.  Judgement/insight were good and the Veteran was alert and oriented times three.  A GAF score of 52 was assigned.  

VA treatment records document that the Veteran participated in a TBI support group on three occasions in April 2014.

The Veteran attended and participated in the Annual AFF Congressional Gala at the Ronald Regan Building in April 2014.  He arrived early and was found seated at a reception table by himself.  Soon thereafter, several other Veterans came over to join him.  The Veteran and another Veteran at the table found they had both worked at the Pentagon and spoke about each other's polytrauma program and their time in the military.  The Veteran remained more reserved for most of the dinner and long presentation.  He was introduced to several Veterans at the table and went over and introduced himself to a Veteran seated on the other side with minimal prompting.  In addition, the Veteran spoke with a soldier who is separating from the military and he offered a suggestion to her.  After two and one-half hours, the Veteran noted that dinner had not been served after the head of the AFF had spoken for a long time.  After three hours, the Veteran asked if he could go.  It was noted the Veteran's mood seemed subdued but with minimal prompting, he benefitted from participating, especially during the reception.

VA treatment records document that the Veteran participated in a TBI support group on two occasions in May 2014.  

A June 2014 CT of the lumbar spine contained an impression of: 1. Status post posterior lateral fusion and right facetectomy at L4-L5; hardware appears intact without peri hardware lucency.  2. There is an intervertebral disc spacer at L4-L5 without significant osseous fusion across the disc space; there is irregularity and sclerosis of the endplates.  3. There is no significant spinal canal stenosis.

A June 2014 VA neurosurgery clinic note reveals that the Veteran was status post L4/5 TLIF and that he reported being the same since his last visit.  His back pain was still manageable, stable, and improved since surgery.  The Veteran also felt his right lower extremity was better and it continued to gain strength up to a point and was now stable, though worse with too much activity.  The Veteran reported that physical therapy had really helped him and that he did not use a cane unless going further distances.  The Veteran denied any new neurological symptoms and any new numbness/tingling.  Physical examination revealed that the lumbar spinous processes were nontender and that the paraspinous muscles were nontender without spasm.  Range of motion in the lumbar spine was reported as full, but no actual measurements were provided.  Motor examination revealed normal bulk and tone.  Strength and deep tendon reflexes were normal.  Sensory examination revealed that the Veteran still had decreased sensation in the right lower extremity, specifically the lateral and medial lower leg.  Ankle clonus, bilateral straight leg, and Romberg testing were negative.  Gait was reportedly nonataxic with normal heel, toe, and tandem gait.  The Veteran was noted to walk with a cane.  The assessment was status post L4/5 TLIF.  His CT scan was reportedly viewed and showed incomplete fusion across L4/5, however the Veteran was noted to be stable without any new complaints.  

A July 2014 VA primary care note documented that the Veteran was on Topamax for a past partial seizure, but that an EEG had been conducted that showed no seizure activity.  The Veteran thought he might have had "two partial seizures" recently but also felt it could be due to stress or pain.  He wanted to hold off on another EEG for now.

A July 2014 VA polytrauma note documents that the Veteran continued to express heightened awareness and increased anxiety and stress about Muslims around him.  He had an incident that day at the hospital, and again there was nothing to be concerned about.  The Veteran acknowledged that he is more hypersensitive and it is likely due to his anniversary time and the Muslim holiday time period.  

A July 2014 VA mental health note documents that the Veteran reported doing not bad and keeping busy with VA appointments, though he was no longer coming to polytrauma group since the therapist got transferred.  Things at home were stable.  The Veteran was not getting out much except for appointments.  Mental status examination revealed that he was casually dressed and cooperative with good hygiene and good eye contact.  Psychomotor activity was normal and speech was of normal rate and volume.  Thought process was logical and goal directed.  The Veteran reported his mood as "up and down, stable," and exhibited full range affect.  The Veteran denied auditory/visual hallucinations and paranoia.  He reported staying hypervigilant and having some hopelessness, helplessness, worthlessness and guilt at times.  The Veteran reported having limited interests and having gotten into a rut, though he realized he had to make choices if he wants to make changes and that he needed to use strategies he learned in the group.  He had not been getting out of the house, going only to VA and then coming home.  Appetite was reportedly ok and the Veteran was eating regular meals.  Energy was noted to be low and the Veteran indicated that he had not been sleeping well, as he was not able to stay asleep and was waking up after an hour, wide awake.  The Veteran denied manic symptoms and any suicidal or homicidal ideation, plan or intent.  Judgement and insight were good and the Veteran was alert and oriented times three.  A GAF score of 52 was assigned.  

VA treatment records document that the Veteran attended community reintegration outings to Haines Point three times in July 2014, three times in August 2014, and three times in September 2014.  The purpose of the group was noted to be to provide opportunities for socialization, for leisure education and to improve functioning in the community.  The Veteran also participated in a community reintegration outing with the purpose of visiting and learning about the Freedom Aquatic Center in September 2014.  

A September 2014 VA mental health note documents that the Veteran reported doing ok and keeping busy with VA.  He reportedly had joined a fitness group through a partnership with the VA and went walking with them every Saturday.  The Veteran indicated that things at home were.  He reported very low mood about one time per month due to a combination of triggers, to include the anniversary of the in-service blast injury.  Mental status examination revealed that he was casually dressed, cooperative, made good eye contact, had normal psychomotor activity, and had good hygiene.  Speech was of normal rate and volume.  Thought process was logical and goal directed.  Mood was reportedly "very low," and the Veteran had full range affect.  He denied auditory/visual hallucinations and noted a tiny bit of paranoia given so much going on in the news.  He denied hopelessness, helplessness, worthlessness and guilt.  The Veteran indicated he had limited interests, ok appetite, low energy, and was not sleeping well.  The Veteran denied manic symptoms and any suicidal or homicidal ideation, plan or intent, though he did have thoughts at times of life not being worth living.  There was no active suicidal ideation, plan or intent as he did not want to let anyone down.  Judgement and insight were good and the Veteran was alert and oriented times three.  A GAF score of 52 was assigned.  

A VA mental health note dated in October 2014 documents that the Veteran denied current suicidal/homicidal ideation, intent, or plan, but reported one suicide attempt about three years ago.  He denied ideation, attempts, or self-injury behaviors since that time and identified his wife and sons as his primary protective factor.  It was noted that the Veteran arrived 40 minutes late to this appointment due to visiting a friend who had complications following surgery.  The Veteran described current symptoms of PTSD, including significant anxiety and hypervigilance.  He also noted experiencing depression and "verbal outbursts" for some time.  He reported having multiple combat deployments spanning a five year time period. He indicated this had a negative impact on his emotional and physical health as well as his marriage and his sons.  

VA treatment records document that in October 2014, the Veteran attended a community reintegration outing to Haines Point; a community reintegration outing for the first Northern Virginia lunch group; and participated in a psychology group called mind/body wellness group.  

An October 2014 VA mental health note documents that the Veteran described current symptoms of PTSD, including significant anxiety and hypervigilance.  He also noted experiencing depression and "verbal outbursts" for some time.  

An October 2014 VA neurology outpatient note documents that the Veteran reported his low back pain was worse, and that it was hurting a lot.  Pain could range from a level four up to a level eight.  It was noted that the Veteran had discontinued physical therapy, but had been swimming.  He reported that the other day while swimming, his right lower extremity went numb.  The numbness reportedly comes and goes.  He also described as a shooting pain in his right lower extremity.  Symptoms in his left lower extremity were very rare.  The Veteran reported that he had falling and was using his cane.  He felt he fell more especially when the leg was weak.  Weakness was reportedly brought on by too much activity, especially standing.  It was noted that the Veteran was still using his bone stimulator and had decided he would not go skiing this year.  Physical examination revealed the lumbar spinous processes were nontender.  The paraspinous muscles were nontender without spasm.  Range of motion in the lumbar spine was reported as full, but no actual measurements were provided.  Motor examination revealed normal bulk and tone.  Strength was normal and deep tendon reflexes were 2+.  Sensory examination revealed that he was intact to light touch and sharp stimuli.  Straight leg raise was bilaterally negative.  An October 2014 CT of the lumbar spine contained an impression of redemonstrated postsurgical changes of posterior lateral fusion at L4-L5; mild lucency measuring 1-2 mm about the L4 screws within the pedicles bilaterally, slightly more prominent from the prior exam.  The hardware appeared intact.  Intervertebral disc spacer at L4-L5 without significant osseous fusion across the disc space.  At L5-S1 there was narrowing of the left lateral recess which impinge upon the descending left S1 nerve root.  Please correlate clinically for symptoms of left S1 radiculopathy.

A November 2014 VA medical opinion indicates that the severity of the Veteran's combined PTSD and cognitive disorder on his social and occupational functioning was the subject of discussion.  A review of the records indicated that the Veteran was functioning poorly after the injury and that a review of the current VA records indicate that he is still functioning at a very low level because of his illnesses and injuries.  He appears isolated and withdrawn and significantly cognitively impaired.  Although GAF scores are not used anymore, the examiner would rate him as a 40 and emphasize that it appears his employment status is tenuous and special accommodations had been made for him.  The Veteran did not appear to have any violence associated with his injuries and appeared from the records to be mostly docile, anxious and depressed.  

Analysis

Prior to addressing the merits of the claims being adjudicated in this decision, the Board notes that the Veteran failed to report to several VA examinations scheduled in conjunction with the Board's October 2012 remand, as he was of the mindset that he does not need any compensation and pension examinations.  See July 2013 response form.  Although these examinations would have been helpful in ascertaining the current severity of the Veteran's service-connected conditions and may have been helpful in granting increased ratings as of the dates of the missed examinations, the Board will analyze the claims based on the already voluminous evidence of record.  See 38 C.F.R. §3.655 (2014). 

Prior to addressing the merits of the claim for entitlement to an increased initial evaluation for cognitive impairment and other residuals of TBI not otherwise classified, the Board notes that although memory loss is a symptom associated with the General Rating Formula for Mental Disorders, the Veteran's complaints of memory loss have been attributed to his TBI and will only be considered in the context of whether an increased rating for that disability is warranted.  Similarly, any emotional/behavioral dysfunction will be rating under the General Rating Formula for Mental Disorders instead of the criteria for TBI since a diagnosis of a mental disorder is of record and separately evaluated.  

The Board reiterates that the Veteran is separately rated for slow speech due to TBI; status post facial burn with loss of eyebrow hair and metal fragments in head with residual scars; mild paralysis of the ocular nerve, left eye, due to TBI; trichiasis, right lower lid with keratoconjuctivitis, right eye and inactive chorioretinits, left eye with scotomata bilaterally; post tympanoplasty, right ear with residual scar; tinnitus; taste disturbance due to TBI; and decreased sensation of the musculocutaneous nerve, left forearm, due to TBI.  As service connection for these disorders has been separately established, any complaints made in regards to them will not be considered in the context of whether an increased rating is warranted for the service-connected TBI.  The Board also reiterates that of the separately noted disabilities, only the slow speech due to TBI is also on appeal, and will be addressed separately.  

At this juncture, the Board acknowledges that there are several references in the treatment records to the Veteran having a problem with seizures as a result of his TBI.  VA treatment records, however, include documentation that the Veteran "had an EEG which did not show evidence of seizures;" that a CT scan of his head also "showed no acute changes;" and that the Veteran had an "event that sounds like an episode of hypnagogic sleep paralysis."  See VA neurology notes.  In addition, an August 2013 VA neurology note indicates that "of note this patient does not have a diagnosis of seizures.  He was recently admitted for an episode that in my opinion was not consistent with seizure. EEG was normal and the Topamax he is taking is for headaches."  

The preponderance of the evidence of record does not support the assignment of a rating in excess of 40 percent for cognitive impairment and other residuals of TBI not otherwise classified, at any time between October 23, 2008, and January 17, 2011.  In order to support the assignment of the next highest rating (70 percent) during this time frame, there must be evidence that the Veteran met a "3" level of impairment under one of the facets of cognitive impairment and other residuals of TBI not otherwise classified.  Level 3 facets are provided for objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions resulting in moderate functional impairment; for moderately severely impaired judgment (for even routine and familiar decisions, occasionally unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision); for when social interaction is inappropriate most or all of the time; for when the Veteran is often disoriented to two or more of the four aspects (person, time, place, situation) of orientation; for when motor activity is moderately decreased due to apraxia; for when visual spatial orientation is moderately severely impaired (gets lost even in familiar surroundings, unable to use assistive devices such as GPS (global positioning system)); and for when the Veteran is unable to communicate either by spoken language, written language, or both, at least half of the time but not all of the time, or to comprehend spoken language, written language, or both, at least half of the time but not all of the time (may rely on gestures or other alternative modes of communication; able to communicate basic needs).  

In this case, although the November 2009 letter from VA speech-language pathologist P.M.H. reports the latest testing (11/10/09) documented that the Veteran was capable of completing addition and subtraction problems independently with 100% accuracy without using a calculator; that the Veteran had deficits with word retrieval and reading comprehension of lengthy materials; that he scored 43/60 on the Boston Naming Test, where the mean is 55, and tried to compensate in conversation by using descriptions, but if he is asked questions during a presentation or discussion, he is apt to become tangential and have difficulty remembering his topic; and that the Veteran was unable to complete reading and vocabulary testing due to becoming confused by the visual presentation, there is no objective evidence on testing of moderate impairment of memory, attention, concentration, or executive functions.  

In addition, there is no evidence of moderately severely impaired judgment.  Rather, the examiner who conducted the May 2009 VA psychiatric examination indicated that the Veteran's judgment was moderately impaired, and the Veteran's judgment was consistently reported to be fair in VA treatment records dated prior to January 18, 2011.  See VA psychiatry notes dated September 2009, October 2009, January 2010 and January 2011.  There is also no evidence to support a finding that the Veteran's social interaction was inappropriate most or all of the time.  Rather, the evidence of record dated prior to January 18, 2011, indicates that the Veteran was able to consistently participate in group therapy through VA, to include attending swimming, kayaking, strength training, and exercise/wellness classes, such as spinning and Pilates, during which it was frequently noted that he was social with other participants.  

Moreover, there is no evidence that the Veteran was often disoriented to two or more of the four aspects (person, time, place, situation) of orientation at any time prior to January 18, 2011.  In fact, VA psychiatry notes dated in December 2008, March 2009 and May 2009 reported that he was oriented times three; VA psychiatry notes dated in September 2009, October 2009, January 2010 and January 2011 describe the Veteran as fully oriented; a January 2010 VA mental health note reported that the Veteran was oriented and a June 2010 VA polytrauma psych note reported that the Veteran was oriented to person, place and time; and the examiner who conducted the May 2009 VA psychiatric examination indicated that the Veteran was well oriented.  

There is also no evidence that the Veteran's motor activity was moderately decreased due to apraxia at any time prior to January 18, 2011.  In fact, although motor weakness was noted at the time of the September 2007 VA examination, motor activity prior to and after that examination was consistently reported to be normal in both VA and private treatment records.  See records from Walter Reed dated May 2007, July 2007, November 2007, June 2008, October 2008 and December 2008; VA neurology outpatient consult notes dated August 2007 and January 2009; VA psychiatry note dated January 2010; see also May 2009 VA examination report (motor activity was normal).  

There is also no evidence that the Veteran's visual spatial orientation was moderately severely impaired at any time prior to January 18, 2011.  In fact, the examiner who conducted the May 2009 VA examination specifically reported that visual spatial orientation appeared normal and although VA speech-language pathologist P.M.H. reported in a November 2009 letter that the Veteran became confused by the visual presentation on a reading test and was unable to complete the rest, s/he does not report that the Veteran's confusion amounts to moderately severe impairment in circumstances outside of the testing environment.  

Lastly, there is no evidence that the Veteran is unable to communicate either by spoken language, written language, or both, at least half of the time but not all of the time, or to comprehend spoken language, written language, or both, at least half of the time but not all of the time (may rely on gestures or other alternative modes of communication; able to communicate basic needs), at any time prior to January 18, 2011.  Rather, the May 2009 VA examiner specifically noted that the Veteran was able to communicate well with written and spoken language and communication impairment was only noted to be mild in letters written by VA speech-language pathologist P.M.H. and VA physician S.K. in November 2009.  

For all these reasons, the assignment of the next highest (70 percent) rating for cognitive impairment and other residuals of TBI not otherwise classified, is not warranted at any time between October 23, 2008, and January 17, 2011.  

The preponderance of the evidence of record does not support the assignment of a rating in excess of 70 percent for cognitive impairment and other residuals of TBI not otherwise classified, at any time as of January 18, 2011.  In order to support the assignment of the next highest rating (100 percent) as of this date, there must be evidence that the Veteran met a "total" level of impairment under one of the facets of cognitive impairment and other residuals of TBI not otherwise classified.  Total impairment is provided for objective evidence on testing of severe impairment of memory, attention, concentration, or executive functions resulting in severe functional impairment; severely impaired judgment (for even routine and familiar decisions, usually unable to identify, understand, and weigh the alternatives, understand the consequences of choices, and make a reasonable decision.  For example, unable to determine appropriate clothing for current weather conditions or judge when to avoid dangerous situations or activities); if the Veteran is consistently disoriented to two or more of the four aspects (person, time, place, situation) of orientation; when motor activity is severely decreased due to apraxia; when visual spatial orientation is severely impaired (may be unable to touch or name own body parts when asked by the examiner, identify the relative position in space of two different objects, or find the way from one room to another in a familiar environment); when a Veteran is completely unable to communicate either by spoken language, written language, or both, or to comprehend spoken language, written language, or both (unable to communicate basic needs); and when there is a persistently altered state of consciousness, such as vegetative state, minimally responsive state, coma.  

In this case, at the time of the January 18, 2011, VA TBI examination, the examiner noted a complaint of mild memory loss attention, concentration, or executive functions, but specifically reported the absence of objective evidence on testing; reported that the Veteran was only occasionally disoriented to one of the four aspects; reported that the Veteran had normal motor activity most of the time, but that it was mildly slowed at times due to apraxia; reported that the Veteran's visual spatial orientation was only moderately impaired; indicated that the Veteran only exhibited occasional impairment of communication; and reported that the Veteran's consciousness was normal.  There is also no indication from the VA and private treatment records dated as of January 18, 2011, that any testing of memory, concentration, and/or executive function was conducted other than a report of low scores on memory, attention, reading comprehension and listening comprehension testing noted in a May 2013 VA speech pathology consult, and the Board again notes that the Veteran failed to report for VA examination scheduled in conjunction with its October 2012 remand.  

In addition to the foregoing, the Veteran was consistently noted to be either grossly oriented or oriented times three in treatment records dated after January 18, 2011.  See VA psychiatry progress notes dated March 2011, June 2011, September 2011 and October 2011; see also VA mental health notes dated March 2012, April 2012, September 2012, May 2013, August 2013, October 2013, March 2014, July 2014 and September 2014; see also July 2013 VA neurology outpatient note.  The Veteran's motor activity was also consistently reported as normal, full strength, or within normal limits both prior to and after a September 2011 record from Walter Reed that had noted some motor dysfunction.  See VA neurology outpatient consult notes dated July 2011, September 2011, July 2013, December 2013, January 2014, March 2014 and October 2014; records from Walter Reed dated October 2011 and June 2013; November 2011 VA examination report; December 2011 VA neurology consult note; June 2014 VA neurosurgery clinic note; VA mental health notes dated January 2012, March 2012, April 2012 and July 2012.  In addition, the Veteran's deficits in communication were only noted to be moderately severe in a May 2013 VA speech pathology consult.  

For all these reasons, the assignment of the next highest (100 percent) rating for cognitive impairment and other residuals of TBI not otherwise classified, is not warranted at any time as of January 18, 2011.  

The evidence of record supports the assignment of an initial rating of 70 percent for PTSD as of October 23, 2008.  The Board first notes that in an October 2011 letter, Dr. M. reported that it was not possible to differentiate which symptoms were related specifically to PTSD and which were related to depression, not otherwise specified, due to the overlap of symptoms.  Dr. M. indicated that based on the history of the Veteran's conditions, the depression appeared secondary to PTSD and that his PTSD and depression symptoms were causing total social and occupational impairment.  In light of the foregoing, the Board will resolve reasonable doubt in the Veteran's favor by assessing the psychiatric symptomatology of record as attributable to his service-connected PTSD.  See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (when it is not possible to separate the effects of service- and nonservice-connected conditions, the doctrine of reasonable doubt dictates that the Veteran's disability be attributed to the service-connected disability).  Assignment of a 70 percent rating for PTSD as of October 23, 2008, is based primarily on the Veteran's reports of impaired impulse control at work, at home, and while driving, to include while driving his son's friends around; and his frequent assertions that he has thoughts of suicide.  When considering these factors in light of the other subjective symptomatology reported by the Veteran, and the Veteran's wife's testimony at his Board hearing that the Veteran used to be very calm and mild mannered prior to the blast injury and that even their children have to work hard to get him to calm down now, the Board finds that the Veteran's disability picture approximates the criteria for the assignment of a 70 percent rating as of October 23, 2008.  

The evidence of record does not support the assignment of a rating in excess of 70 percent for PTSD at any time during the appellate period being considered in this decision (beginning October 23, 2008).  The Board acknowledges the subjective symptomatology reported by the Veteran and the objective symptomatology he manifested that is documented in treatment records and that was discussed by his wife both in testimony and during the VA examinations she attended.  The Board also acknowledges that the Veteran has been determined by VA to be totally impaired in the occupational sense as of October 3, 2011, and that the question as to whether he is entitled to a TDIU prior to October 3, 2011, remains unadjudicated in this decision.  The fact remains, however, that the Veteran is not totally impaired in the social sense, and total social impairment due to such symptoms is specifically required by the regulations.  See 38 C.F.R. § 4.130, Diagnostic Code 9411.  Rather, the voluminous medical and lay evidence in this case documents that the Veteran has been able to travel, to include overseas and going camping with various family members; that he has consistently participated in group outings through VA, to include to the Air and Space museum and to Haines Point Park; that he has consistently participated in group therapy through VA, to include attending swimming, kayaking, strength training, and exercise/wellness classes, such as spinning and Pilates; that he has volunteered to help other Veterans; that he has attended VA holiday parties and galas; that he participated in a biathlon with his wife; and that he has attended at least one wedding and one funeral during the appellate period.  The fact also remains that while family relationships appear to be strained, the Veteran has remained married to the same woman and has a relationship with his sons, which includes attending their hockey games and taking them and their friends to various places.  For these reasons, the Board does not find that the Veteran's PTSD symptomatology, to include his suicidal ideation and impaired impulse control, have resulted in total social impairment.  In the absence of total social impairment, the preponderance of the evidence supports the 70 percent disability rating assigned for PTSD as of October 23, 2008.  The evidence is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule.  38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102.

The preponderance of the evidence of record does not support the assignment of a rating in excess of 30 percent for slow speech due to TBI at any time between May 1, 2007, and May 26, 2009.  The Board acknowledges the Veteran's report in an April 2009 TBI signs and symptoms questionnaire that he had difficulty speaking and slurred speech.  The Board also acknowledges that in his December 2008 VA Form 9, the Veteran reported that his speech is slower, especially when he is under stress; that he is unable to find the right words to use; that he has trouble with word association; that he stutters a lot when stressed; that slow speech makes it hard for him to perform his job on the engagement team for strategic communications; that he is unable to conduct long briefings or meetings due to slow speech pattern and poor word association; that he cannot confirm to the need at work to brief visitors; that his stuttering causes him to avoid public groups; that he cannot perform his job at the same level as he did in service due to slow speech and cognitive issues; and that he has trouble talking to large groups on official business or at meetings.  The Board finds these assertions to be both competent and credible.  The evidence of record dated between May 1, 2007, and May 26, 2009, however, does not support a finding that the Veteran's slow speech due to TBI merits the assignment of the next highest rating (60 percent) under Diagnostic Code 7202, as there is no evidence he has one-half or more loss of tongue.  In addition, although the Veteran's speech was noted to be sometimes hesitant during VA psychiatric notes dated December 2008, March 2009, and May 2009, it was noted to be of normal rate, volume and tone at those times, and the other medical evidence dated during this time frame consistently reports the Veteran's language as spontaneous, fluent and logical, as well as of normal rate and volume.  See VA treatment records; VA polytrauma speech note.  Moreover, he has only been diagnosed with mild cognitive-communication deficits.  Id. (emphasis added).  

The preponderance of the evidence of record also does not support the assignment of a compensable rating for slow speech due to TBI as of May 27, 2009.  The Board acknowledges the Veteran's May 2010 testimony that he sees a speech pathologist on a fairly frequent basis and that his speech is one of the things he works hardest on for rehabilitation; and that he was used to public speaking and being able to articulate and explain things well, but now it is hard and it is hard to find the right words and associate words correctly.  The Board also acknowledges the Veteran's wife's testimony that she had seen not only slowness in his speech, but slurring of words, and that at the time of the May 2010 hearing, the Veteran's representative noted on the record that the Veteran's speech pattern was a little slow and that it was not because of an accent.  The Board finds these assertions to be both competent and credible.  The evidence of record dated as of May 27, 2009, however, does not support a finding that the Veteran's slow speech due to TBI merits the assignment of the next highest rating (30 percent) under Diagnostic Code 7202, as there is no evidence of marked speech impairment.  This is so because even though the Veteran reported difficulties in finding the right words to say, with processing sounds or forming words, and with finding words at the time of the May 27, 2009, VA examination; his speech was noted to be slow and hesitant at times during mental status evaluation at the time of a June 2010 VA polytrauma psych note; and the Veteran reported difficulty in finding the right words to say (expressing himself), pronouncing words (articulation), and with speech and word recognition at the time of the November 2011 VA examination, the VA examiner who conducted the May 27, 2009, VA examination reported in an addendum that the Veteran's speech was normal, the November 2011 VA examiner specifically indicated that there was no pathology to render a diagnosis in regards to the slow speech due to TBI disability, and the Veteran's speech has consistently been reported to be normal; of regular rate, rhythm/flow, and volume; fluid; and logical and coherent.  See VA treatment records.  In addition, a May 2013 VA speech pathology consult reveals that speech examination revealed respiration, phonation, articulation, resonance and prosody were within full limits and the VA treatment records associated with speech therapy dated after May 27, 2009, continue to assess only mild cognitive-communication deficits.  See VA polytrauma speech notes and VA polytrauma speech monthly progress (emphasis added).  

Moreover, as noted above when discussing the Veteran's cognitive impairment and other residuals of TBI not otherwise classified, there is no evidence that the Veteran is unable to communicate either by spoken language, written language, or both, at least half of the time but not all of the time, or to comprehend spoken language, written language, or both, at least half of the time but not all of the time (may rely on gestures or other alternative modes of communication; able to communicate basic needs), at any time prior to January 18, 2011.  Rather, the May 2009 VA examiner specifically noted that the Veteran was able to communicate well with written and spoken language and communication impairment was only noted to be mild in letters written by VA speech-language pathologist P.M.H. and VA physician S.K. in November 2009.  

For all these reasons, the assignment of the next highest (30 percent) rating for slow speech due to TBI is not warranted at any time as of May 27, 2009.  

The preponderance of the evidence of record does not support the assignment of a rating in excess of 10 percent for IVDS without DJD of the lumbar spine at any time between May 1, 2007, and January 17, 2011.  This is so because the Veteran did not exhibit forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees at any time between those dates.  Rather, at worst, forward flexion of the thoracolumbar spine was limited to 90 degrees.  See September 2007 VA examination report; see also Plate V, 38 C.F.R. § 4.71a (2013).  There is also no evidence that the Veteran exhibited a combined range of motion of the thoracolumbar spine not greater than 120 degrees.  Rather, he exhibited a combined range of motion of 240 degrees during the September 2007 VA spine examination.  In addition to the foregoing, although there was objective evidence of tenderness to palpation at the left lumbar paraspinal muscles at the time of the September 2007 VA examination, there was no objective evidence of spasm and the Veteran's posture and gait were described as within normal limits.  Prior to the September 2007 VA examination, there was no tenderness to palpation noted, the Veteran's gait was reported as normal, intact and spontaneous, and his stance was reported as normal.  See records from Walter Reed dated May 2007 and July 2007; August 2007 VA neurology outpatient consult note; September 2007 VA rheumatology consult note.  For all these reasons, the assignment of a 20 percent rating under the General Rating Formula for Diseases and Injuries of the Spine is not warranted for IVDS without DJD of the lumbar spine at any time between May 1, 2007, and January 17, 2011.  

There is also no evidence of incapacitating episodes of IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months so as to support the assignment of a 20 percent rating between May 1, 2007, and January 17, 2011, under the Formula for Rating IVDS Based on Incapacitating Episodes.  Although there is evidence of IVDS, there is no indication from the VA or Walter Reed treatment records that bed rest was ever prescribed.  

Consideration has been given to any functional impairment and any effects of pain on functional abilities.  The Board acknowledges that there was objective evidence of pain during range of motion testing with flexion, extension, and bilateral lateral flexion at the time of the September 2007 VA examination.  More specifically, there was pain beginning at 65 degrees of flexion, at 20 degrees of extension and right lateral flexion, and at 30 degrees of left lateral flexion, with the Veteran being able to flex to 90 degrees, to extend to 30 degrees, and to laterally flex on both sides to 30 degrees.  Even if range of motion was limited by pain beyond that shown during the September 2007 examination, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss.  Mitchell v. Shinseki, 25 Vet. App. 32, 36-38 (2011).  Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss.  Id. at 43; see 38 C.F.R. § 4.40.  In this case it does not.  More specifically, there was no evidence of additional loss of motion on repetitive use of the joint for all ranges of motion at the time of that examination.  

In light of the foregoing, the Board finds that a rating in excess of 10 percent is not warranted under 38 C.F.R. §§ 4.40 and 4.45 pursuant to the guidelines set forth in DeLuca for IVDS without DJD of the lumbar spine at any time between May 1, 2007, and January 17, 2011.  This is so because even taking into account the findings of pain at 65 degrees of forward flexion during the September 2007 VA spine examination, the Veteran was still able to forward flex to 90 degrees after repetitive range of motion testing, which is 30 degrees away from the amount needed to support a 20 percent rating under the General Rating Formula for Diseases and Injuries of the Spine.  See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2014). 

The preponderance of the evidence of record also does not support the assignment of a rating in excess of 20 percent for IVDS without DJD of the lumbar spine between January 18, 2011, and November 1, 2011.  This is so because the Veteran did not exhibit forward flexion of the thoracolumbar spine 30 degrees or less at any time between these dates.  Rather, at worst, forward flexion of the thoracolumbar spine was limited to 40 degrees.  See November 2011 VA physical therapy initial evaluation note; see also Plate V, 38 C.F.R. § 4.71a (2013).  There is also no evidence that the Veteran exhibited favorable ankylosis of the entire thoracolumbar spine as this spinal segment was not fixed in neutral position (zero degrees) at the time of a January 2011 VA examination.  See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243, Note (5).  For all these reasons, the assignment of the next highest (40 percent) rating under the General Rating Formula for Diseases and Injuries of the Spine is not warranted for IVDS without DJD of the lumbar spine between January 18, 2011, and November 1, 2011.  

There is also no evidence of incapacitating episodes of IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months so as to support the assignment of a 40 percent rating between January 18, 2011, and November 1, 2011, under the Formula for Rating IDS Based on Incapacitating Episodes.  Although there is evidence of IVDS and the Veteran reported flare-ups of low back pain that were severe and lasting hours on a weekly basis with resulting functional impairment in the form of limited mobility at the time of the January 2011 VA spine examination, there is no indication from the VA or Walter Reed treatment records that bed rest was ever prescribed.  

Consideration has been given to any functional impairment and any effects of pain on functional abilities.  The Board acknowledges that there was objective evidence of painful motion for all ranges of motion tested at the time of the January 2011 VA examination, to include pain following repetitive motion; however, the examiner did not indicate at which degree of motion the pain began.  Even if range of motion was limited by pain beyond that shown during the January 2011 VA examination, the Board again notes that pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss.  Mitchell, 25 Vet. App. at 43; see also 38 C.F.R. § 4.40.  In this case it does not, as there was no additional limitation of motion after three repetitions.  

In light of the foregoing, the Board finds that a rating in excess of 20 percent is not warranted under 38 C.F.R. §§ 4.40 and 4.45 pursuant to the guidelines set forth in DeLuca for IVDS without DJD of the lumbar spine between January 18, 2011, and November 1, 2011.  This is so because even taking into account the findings of pain during the January 2011 VA examination, the Veteran was still able to forward flex to 50 degrees after repetitive range of motion testing, which is 20 degrees away from the amount needed to support the next highest (40 percent) rating under the General Rating Formula for Diseases and Injuries of the Spine.  See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2014). 

The preponderance of the evidence of record does support the assignment of a 40 percent rating for IVDS without DJD of the lumbar spine as of November 1, 2011, the date of a VA examination which showed forward flexion limited to 20 degrees.  

A rating in excess of 40 percent is not warranted at any time after November 1, 2011.  In order to merit the assignment of the next highest (50 percent) rating under the General Rating Formula for Diseases and Injuries of the Spine, there must be unfavorable ankylosis of the entire thoracolumbar spine.  No such evidence exists in this case.  See treatment records from VA and Walter Reed.  In fact, the examiner who conducted the November 2011 VA examination specifically noted the absence of ankylosis.  

Nor is a rating in excess of 40 percent warranted as of November 1, 2011, for the Veteran's IVDS without DJD of the lumbar spine under the Formula for Rating IVDS Based on Incapacitating Episodes.  Although at the time of the November 2011 VA examination the Veteran reported an incapacitating episode for over 90 days between July 12, 2011, and November 1, 2011, with bed rest recommended by Dr. Z., the reported incapacitating episodes to not have a total duration of at least 6 weeks during the past 12 months, and the reported recommended bed rest is not corroborated by the VA and private treatment records of record.  

The Board has considered whether the Veteran manifests any associated objective neurologic abnormalities so as to warrant a separate rating under an appropriate diagnostic code.  See 38 C.F.R. § 4.71a, Note (1).  The Veteran has consistently denied any bowel or bladder impairment; however, the evidence of record indicates that he has complained of radiating pain down his right lower extremity and was diagnosed with right L5 radiculopathy during a VA examination conducted on January 18, 2011.  In addition, the examiner who conducted the November 1, 2011, VA examination provided an addendum opinion that the Veteran's erectile dysfunction was secondary to his lumbar IVDS.  Given the foregoing, separate ratings are warranted for right L5 radiculopathy and erectile dysfunction effective January 18, 2011, and November 1, 2011, respectively.  

The Board has also considered whether the Veteran is entitled to a temporary total evaluation under the provisions of 38 C.F.R. § 4.30 based on the need for convalescence following surgery performed on his lumbar spine at Walter Reed in October 2011 and October 2013.  The applicable laws and regulations provide that a temporary total rating may be assigned for a period of one, two or three months if at least one month of convalescence is necessitated by surgery for a service-connected disability, with such benefits payable from the date of entrance into the hospital or the date of outpatient treatment for the period in question.  38 C.F.R. § 3.401(h)(2), 4.30.  An extension of the total convalescence rating is available up to one year from the initial date of hospitalization.  38 C.F.R. § 4.30(b).  The Board finds that entitlement to a temporary total evaluation pursuant to 38 C.F.R. § 4.30 is not warranted in this case as the Veteran has not requested such compensation and the evidence of record does not suggest he had any need for convalescence following either lumbar spine surgery.  See VA and private treatment records.  

The Board has also considered whether separate, compensable ratings would be warranted for the scars noted on the Veteran's lumbar spine.  See Esteban v. Brown, 6 Vet. App. 259, 262 (1994) (evaluations for distinct disabilities resulting from the same injury can be combined so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition.)  In this case, however, the Veteran does not contend, and the evidence does not show, that a separate compensable rating is warranted for any of the lumbar spine scars.  See 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805 (2007).  This is so because none of the scars have been described as painful and/or unstable and the total area of all related scars was not greater than 39 square cm (6 square inches).  See November 2011 VA examination report; October 2013 VA physical medicine rehab outpatient note.  As such, the assignment of a separate, compensable rating for the scars on the Veteran's lumbar spine is not warranted.

The preponderance of the evidence of record does not support the assignment of an initial evaluation in excess of 20 percent for sciatic nerve deficiency of the left leg due to IVDS of the lumbar spine.  The Board has considered the assertions made by the Veteran and his wife regarding the symptomatology associated with his left lower extremity disability and finds that they are both competent to make such assertions and that these assertions are credible.  When it evaluates all the evidence of record dated throughout the appellate period, however, the Board does not find that the preponderance of the medical and lay evidence supports a finding that the left leg sciatic nerve deficiency is moderately severe so as to support the next highest, or 40 percent rating, under Diagnostic Code 8520.  This is so because a November 2007 record from Walter Reed specifically noted that the Veteran continued to have mild symptoms and that EMG had been normal, which suggested that whatever nerve root impingement was present was mild.  In addition, when evaluated during the course of the appeal, the Veteran's gait was regularly noted to be normal, stable or unimpeded and, if not, was described as having a slight limp or mildly antalgic; sensation was regularly noted to be slightly decreased; the only motor deficit was noted during the September 2007 VA examination (motor weakness of the left hip on adduction 4/5), but was consistently described as normal thereafter; and there was no evidence of toe drop..  See medical evidence (emphasis added).  The Board also notes that the Veteran's left lower extremity symptomatology complaints have lessened in the more contemporaneous evidence of record, and he was more often seen with complaints involving the right lower extremity.  See VA and private treatment records.  Moreover, straight raise testing on the left has recently been consistently negative and the more contemporaneous records from Walter Reed show that there was no decreased response to tactile stimulation of the entire left leg and no decreased response to stimulation by vibration on either leg/foot.  For these reasons, a rating in excess of 20 percent is not warranted for sciatic nerve deficiency of the left leg.  

Extraschedular Consideration

The rating schedule represents, as far as is practicable, the average impairment of earning capacity.  Ratings will generally be based on average impairment.  38 C.F.R. § 3.321(a), (b) (2014).  To afford justice in exceptional situations, an extraschedular rating can be provided.  38 C.F.R. § 3.321(b).

The Court has clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted.  First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate.  Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms."  Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating.

The symptoms exhibited by the Veteran's cognitive impairment and other residuals of TBI not otherwise classified; PTSD; slow speech due to TBI; IVCDS without DJD of the lumbar spine; and sciatic nerve deficiency of the left leg due to IVDS of the lumbar spine are all contemplated by the rating criteria and the Board finds that the rating criteria reasonably describe the Veteran's disabilities.  Referral for consideration of an extraschedular rating is, therefore, not warranted for any of the service-connected disabilities.  See Thun v. Peake, 22 Vet. App. 111 (2008).

ORDER

An initial rating in excess of 40 percent for cognitive impairment and other residuals of TBI not otherwise classified is denied between October 23, 2008, and January 17, 2011.  

An initial rating in excess of 70 percent for cognitive impairment and other residuals of TBI not otherwise classified is denied as of January 18, 2011.  

An initial rating of 70 percent, and not higher, for PTSD is granted as of October 23, 2008, subject to the laws and regulations governing the payment of monetary benefits. 

An initial rating in excess of 30 percent for slow speech due to TBI is denied between May 1, 2007, and May 26, 2009.  

An initial compensable rating for slow speech due to TBI is denied as of May 27, 2009.  

An initial rating in excess of 10 percent for IVDS without DJD of the lumbar spine is denied prior to January 18, 2011.  

An initial rating in excess of 20 percent for IVDS without DJD of the lumbar spine is denied between January 18, 2011, and November 1, 2011.  

An initial rating of 40 percent, and not higher, has been met for IVDS without DJD of the lumbar spine as of November 1, 2011, subject to the laws and regulations governing the payment of monetary benefits. 

An initial separate evaluation for right L5 radiculopathy is granted as of January 18, 2011.  

An initial separate evaluation for erectile dysfunction is granted as of November 1, 2011.  

An initial rating in excess of 20 percent for sciatic nerve deficiency of the left leg due to IVDS of the lumbar spine is denied.



REMAND

The Board remanded the claim for entitlement to an increased initial evaluation for PTSD and cognitive disorder due to traumatic brain injury TBI, rated as 50 percent disabling for the period from May 1, 2007, to October 22, 2008, in October 2012 and October 2014 in order to obtain a retrospective medical opinion ascertaining the severity of the combined effects of the Veteran's PTSD and his TBI-related cognitive disorder from May 1, 2007 to October 22, 2008.  Although an opinion was obtained following the October 2014 remand, it addressed the current severity of these disabilities rather than the question posed by the Board.  Where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance.  Stegall v. West, 11 Vet. App. 268 (1998).  Obtaining a retrospective medical opinion to ascertain the severity of the combined effects of the Veteran's PTSD and his TBI-related cognitive disorder from May 1, 2007 to October 22, 2008, must be accomplished on remand.  The claim for entitlement to a TDIU during the period prior to October 3, 2011, is inextricably intertwined with this claim.  See Harris v. Derwinski, 1 Vet. App. 180, 183 (1990) (issues are inextricably intertwined when they are so closely tied together that a final Board decision cannot be rendered unless all are adjudicated).  As such, a decision on the claim for entitlement to a TDIU will be deferred.  

Accordingly, the case is REMANDED for the following action:

1.  Make arrangements with an appropriate VA medical facility to obtain a retrospective medical opinion ascertaining the severity of the combined effects of the Veteran's PTSD and his TBI-related cognitive disorder from May 1, 2007, to October 22, 2008.  The reviewer must be provided with a copy of this remand as well as the entire claims folder and any pertinent records located in the Veteran's electronic files.  The reviewer must assess the combined severity of PTSD and cognitive disorder using treatment records, lay statements, and examination reports from the pertinent time period.  To the extent possible, the reviewer should also provide global assessment of functioning (GAF) scores.  The reviewer must provide a complete rationale for any stated opinion.  If the reviewer is not able to provide the requested opinion, he or she should explain why.

2.  Review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full.  If any development is incomplete, appropriate corrective action is to be implemented.

3.  Finally, readjudicate the remaining claims.  If any benefit sought on appeal remains denied, furnish the Veteran and his representative a supplemental statement of the case and provide an appropriate period of time to respond.  The case should then be returned to the Board for further appellate review, if in order. 

The appellant has the right to submit additional evidence and argument on the matters the Board has remanded.  Kutscherousky v. West, 12 Vet. App. 369 (1999).

This claim must be afforded expeditious treatment.  The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner.  See 38 U.S.C.A. §§ 5109B, 7112 (West 2014).



______________________________________________
DENNIS F. CHIAPPETTA
Veterans Law Judge, Board of Veterans' Appeals




Department of Veterans Affairs