Citation Nr: 0010298 Decision Date: 04/18/00 Archive Date: 04/28/00 DOCKET NO. 97-24 807 ) DATE ) MERGED APPEAL ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased evaluation for chronic low back strain, currently evaluated as 20 percent disabling. 2. Entitlement to a total rating based on individual unemployability due to service-connected disability. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. M. Ivey, Associate Counsel INTRODUCTION The veteran served on active duty from February 1968 to April 1971. This appeal arises before the Board of Veterans' Appeals (Board) from two separate rating decisions of the St. Petersburg, Florida, Regional Office (RO) of the Department of Veterans Affairs (VA). Pursuant to a July 1996 rating decision, an evaluation in excess of 10 percent disabling was denied for chronic low back strain. Pursuant to a rating action of August 1998, entitlement to individual unemployability was also denied. Pursuant to an April 1998 rating decision, an increased evaluation of 20 percent disabling was granted for chronic low back strain. The veteran has indicated his continued disagreement with this evaluation. The Board remanded the claim in April 1999 for further development. All requested development has been completed. FINDINGS OF FACT 1. Service-connected chronic low back strain is currently manifested by complaints of chronic low back pain, with radiation into the left lower extremity, with clinical findings for paraspinal tenderness to palpation and varying degrees of limitation of motion (slight to moderate), but absent objective findings of record for a listing of the whole spine to opposite side, positive Goldthwait's sign, marked limitation of forward bending in standing position, or loss of lateral motion. 2. The veteran is considered unemployable as a result of symptomatology attributable to chronic low back strain and an additional nonservice-connected disability. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 20 percent for chronic low back strain are not met. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 1991 & Supp. 1998); 38 C.F.R. § 4.7, 4.10, 4.40, 4.45, 4.59, Part 4, Diagnostic Codes 5292, 5293, 5295 (1999). 2. The criteria for assignment of a total rating based on individual unemployability due to service-connected disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991 & Supp. 1998); 38 C.F.R. §§ 3.340, 3.341, 4.16 (1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Chronic Low Back Strain The veteran contends that his service-connected chronic low back strain has increased in severity, to the point where an increased, compensable, evaluation is warranted. Specifically he maintains that he had stiffness and a lot of pain in his back. The veteran asserts that he experiences total discomfort. The Board finds that the veteran's claim for an increased evaluation is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1998) that is, the claim is plausible. The Board notes that claims for increased evaluations are generally considered to be well grounded, where the disorder was previously service-connected and rated and the claimant subsequently asserts that a higher rating is justified due to an increase in severity since the original rating. Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). The veteran has not alleged, and the record does not indicate, the need to obtain any pertinent records, which have not already been associated with the claims folder. It is accordingly found that all relevant facts have been properly developed, and that the duty to assist him, mandated by 38 U.S.C.A. § 5107(a) (West 1991 & Supp. 1998), has been satisfied. a. Factual Background The VA examined the veteran in September 1995. Upon examination forward flexion was to the point where his fingers were 2 feet from the floor, with a normal reversal of the lumbar curve through this range. There was no muscle spasm and he could extend 20 degrees. Lateral bending was to 30 degrees to either side. Straight leg raising was 80 degrees, bilaterally, and caused no sciatic discomfort. X- rays of the lumbar spine showed minimal degenerative joint disease and no gross bony pathology. The examiner commented that he felt that the veteran's low back complaints were in part secondary to his leg length discrepancy. The veteran was seen in the VA orthopedics clinic between September 1995 and February 1996. In September 1995 the veteran's posture was relaxed. However, there was tenderness over the lower back. Straight leg raising was to 70 degrees on the left and right. The range of motion was about to 80 percent with discomfort on recovery. The assessment was chronic lower back pain. In October 1995 there was tenderness over L5. Flexion and extension were to about 40 percent of range. Minimal hyperextension elicited pain. Straight leg raising on the left was to 20 degrees. The assessment was arthritic discogenic back pain. In November 1995 the veteran complained of increasing low back pain and a MRI was ordered. The December 1995 Magnetic Resonance Imaging (MRI) of the lumbar spine revealed that the anatomic alignment of the lumbar spine was normal without evidence of acute fracture or subluxation. A decreased signal was noted within the L5-S1 disc space consistent with desiccation. The remainder of the discs showed normal brightening on the 12-weighted images. No abnormal signal was noted in the bone marrow. The conus medullaris was noted at the level of the inferior end plate of L1 and showed no evidence of abnormal signal. At L3-4, there was no evidence of spinal stenosis, disc herniation or neural foraminal encroachment although mild facet joint hypertrophy was present. At L4-5, there was evidence of a disc bulge. There was no evidence of spinal stenosis or neural foraminal encroachment. Facet joint hypertrophy was present. At L5-S1, there was evidence of a diffuse disc bulge, slightly asymmetric to the left. There was no evidence of spinal stenosis or neural foraminal encroachment, although facet joint hypertrophy was present. The impressions were diffuse disc bulge at L4-5 and L5-S1; multilevel facet joint hypertrophies and discs desiccation at L5-S1. At L5-S1, the bulge was slightly asymmetric to the left. There was no evidence of spinal stenosis. The January 1996 VA MRI showed that there was no nerve root pressure and some diffuse disc bulge. In February 1996 there was some tenderness over the L5 and S1. The assessment was diffuse disc bulge. The veteran complained of chronic low back pain in May 1996. Straight leg raising was negative. The impression was chronic low back pain. A private medical record dated, March 1997, revealed that spasms were noted at L3-L5. Straight leg raising was negative. Lumbar flexion was to 50 degrees and extension was to 20 degrees. Right and left lateral flexion was to 25 degrees. The physician noted mild lumbar paraspinal tenderness at L3-L5 and bilateral sacroiliac tenderness. X- rays of the lumbar spine revealed an imbalance of the pelvis with a 1/2 inch deficiency of the left ilium. There was also moderate degenerative changes noted as well as decreased disc space at L5/S2 level. The veteran complained of increased back pain in August 1997. There was no tenderness in the paraspinal muscles in the lumbar spine. The assessment was lumbar spine radicular pain. The August 1997 VA radiology report indicated that the veteran's lumbar vertebrae had normal position and alignment. There was no evidence of fracture dislocation or bone destruction. Narrowed L5-S1 disc space with subjacent bony sclerosis and marginal osteophyte formation consistent with degenerative bone disease at L5-S1 was noted. The remainders of the disc space were unremarkable and the posterior elements appeared intact. The impression was mild degenerative spondylosis of the lower lumbar vertebral bodies without significant arthritic changes. The October 1997 VA progress notes indicated that the veteran complained of back pain. Upon examination leg raising was limited; the left was to 40 degrees and the right was to 60 degrees. L4 and S1 radiculopathy was noted. The assessment was degenerative disc disease and low back pain. The November 1997 MRI of the veteran's lumbar spine revealed intervertebral disc space loss at L1-2 and L5-S1 levels. There was intervertebral disc space signal loss at those same levels as well as L4-5. This was compatible with disc desiccation. A small central and right paracentral herniated disc was present with minimal attenuation of the central and right anterolateral aspect of the thecal sac at L1-2. The facet joints were parasagittal oriented. L2-L4 were unremarkable. A small end-plate spur formation was present with slight attenuation on the left anterolateral aspect of the thecal sac at L4-5. There was mild encroachment of the lower aspect of the neurula foramina bilaterally. At L5-S1 moderate facet arthropathy was present. There was moderate end-plate spur formation with attenuation of the anterior aspect of the thecal sac bilaterally and posterior deviation on the S1 nerve roots bilaterally. The neural foramina were bilaterally encroached. The impression was spondylitic changes of the lumbosacral spine. In December 1997 a private physician wrote that he had treated the veteran since 1983. His chief complaint consisted of chronic low back pain with intermittent radiation of pain and / or numbness into both legs. Over the years, the veteran had exacerbations, which required intensive chiropractic care to alleviate his symptoms. The private physician indicated that a review of the most recent lumbar MRI revealed L1 / L2 disc herniation facet arthropathy and neural foramina encroachment. He opined that the veteran's low back disorder was permanent and that the veteran would require chiropractic care as the occasion requires based on his symptoms. The veteran complained of back pain in April 1998. The assessment was degenerative disc disease. The June 1998 VA radiology report indicated that there were mild facet joint degeneration at the L4-5 level and mild generalized degenerative change with no significant acute change from August 1997. In August 1998 a physical residual function capacity assessment was performed. The assessments were degenerative joint disease of the lumbar spine and mild herniated nucleus pulposus at L1-2. The veteran was seen in the VA orthopedic clinic in September 1998. Upon examination there was normal lumbar lordosis. He flexed to 60 degrees with good reversal of the lumbar lordotic curve. He complained of pain with performing this activity. Bending was to 30 degrees to either side. The veteran complained of pain with this activity. He hyhperextended to 10 degrees limited any further extension because of pain. There was no associated spasm or splitting with his range of motion testing. Trunk rotation was to 60 degrees to either side without spasm or splitting. There was no tenderness of the lumbar spine. Straight leg raising was to 70 degrees bilaterally because of back pain. The assessments were degenerative joint disease, lumbar spine disc disease and low back pain. A private physician examined the veteran, in October 1998, for the State of Florida's Office of Disability Determinations. The lumbosacral spine revealed no evidence of spasm, lordosis or severe kyphosis. The veteran was able to flex, extend and side bend the spine through the normal range of motion. In summary there was no motor, reflex or sensory deficits corresponding to any disc group. The private physician concluded that the complaints of back pain were out of proportion to his physical examination findings. In November 1998 the VA computed tomography showed several foci of osteosclerosis in the lumbar spine most consistent with osteoblastic metastatic prostatic carcinoma. At the January 1999 videoconference the veteran testified that he had stiffness, uncomfortability and a lot of pain in his back. He stated that his entire back felt like it was welded and that he had difficulty bending. The veteran reported discomfort in walking and sitting. He indicated that most of the time pain radiated into his left leg and occasionally his right leg. The veteran described constant tightness in the lower part of his back. He maintained that the pain felt like he was being stabbed in the back or as if something was sticking in his back. The veteran testified that he was always in total discomfort. The March 1999 VA radiology report of the veteran's bones revealed that there were multiple areas of markedly abnormal radiotracer uptake within the spine, especially in the region of the sacrum and lower lumbar spine. The VA examined the veteran in October 1999. The veteran was able to bend forward to 60 degrees with satisfactory reversal of the lumbar lordotic curve. Lateral bending was to 30 degrees to either side. Rotation was to 45 degrees to either side and lumbar extension was to 35 degrees. There was some tenderness to palpation of the entire lumbar spine. Straight leg raising was negative. The conclusion was that the veteran had significant discomfort and loss of function of his back with weakness in is left lower extremity and radicular symptoms. b. Analysis In evaluating the veteran's request for increased ratings, the Board considers the medical evidence of record. The medical findings are compared to the criteria in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (1999). In so doing, it is our responsibility to weigh the evidence before us. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (1999). The Board has carefully reviewed the pertinent medical evidence, including the veteran's entire medical history in accordance with 38 C.F.R. § 4.1 (1999) and Peyton v. Derwinski, 1 Vet. App. 282 (1991). Disability evaluations are determined by comparing the veteran's current symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C.A. § 1155 (West 1991 and Supp. 1998); 38 C.F.R. Part 4 (1999). The VA Schedule for Rating Disabilities provides for a 10 percent rating for slight limitation of the lumbar spine. A 20 percent evaluation is assigned for moderate limitation of motion. A 40 percent rating is warranted if there is severe limitation of motion of the lumbar spine. 38 C.F.R. § 4.71 Diagnostic Code 5292 (1999). A 20 percent disability evaluation is warranted for moderate intervertebral disc syndrome, with recurring attacks. A 40 percent disability evaluation is warranted for severe intervertebral disc syndrome with recurring attacks and intermittent relief. A 60 percent evaluation requires pronounced intervertebral disc syndrome with persistent symptoms compatible with sciatic neuropathy (i.e., with characteristic pain, demonstrable muscle spasms, and absent ankle jerk or other neurological findings appropriate to the site of the diseased disc) and little intermittent relief. 38 C.F.R. Part 4, Code 5293 (1999). In a precedent opinion dated December 12, 1997, the Acting General Counsel of the VA held that the criteria under Diagnostic Code 5293, which pertains to intervertebral disc syndrome, "involves loss of range of motion because the nerve defects and resulting pain associated with injury to the sciatic nerve may cause limitation of motion of the cervical, thoracic, or lumbar vertebrae." The Acting General Counsel clarified that a veteran cannot be evaluated under both Diagnostic Code 5293 for intervertebral disc syndrome based in part upon limitation of motion and Diagnostic Code 5292 (limitation of motion of the lumbar spine) due to the provisions of 38 C.F.R. § 4.14 (1998) prohibiting the evaluation of "an identical manifestation under two different diagnoses." VAOPGPREC 36-97 (Dec. 12, 1997). Diagnostic Code 5295 provides for a 10 percent rating for lumbosacral strain with characteristic pain on motion, and a 20 percent rating where there are muscle spasm on extreme forward bending, loss of lateral spine motion. A 40 percent rating is provided for severe lumbosacral strain with listing of the whole spine to opposite side, positive Goldthwait's sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo- arthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. 38 C.F.R. § 4.71, Diagnostic Code 5295 (1999). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part, which becomes painful on use, must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45 (1999). The Court has held that the RO must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40 (1999), which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board has also considered the application of 38 C.F.R. § 4.40 and 4.45 when rating this disability. Spurgeon v. Brown, 10 Vet. App. 194, 196 (1997); DeLuca v. Brown, 8 Vet. App. 202 (1995); Johnson v. Brown, 9 Vet. App. 7, 10-11 (1996). In assessing the functional loss, if any, of a musculoskeletal disability, inquiry must be directed towards findings of less movement that normal; more movement than normal; weakened movement; excess fatigability; incoordination; and painful movement. VA examinations of the low back were conducted in September 1995 and October 1999. At those examinations, there was no muscle spasm and lateral bending was to 30 degrees to either side. In September 1995 forward flexion was to the point where his fingers were 2 feet from the floor, with a normal reversal of the lumbar curve through this range and he could extend to 20 degrees. In October 1999 the veteran was able to bend forward to 60 degrees with satisfactory reversal of the lumbar lordotic curve. Rotation was to 45 degrees to either side and lumbar extension was to 35 degrees. The September 1995 X-rays showed minimal degenerative joint disease and no gross bony pathology. MRI's of the veteran's lumbar spine were done in December 1995, January 1996, February 1996 and November 1997. In December 1995 the impressions were diffuse disc bulge at L4-5 and L5-S1; multilevel facet joint hypertrophies and discs desiccation at L5-S1. At L5-S1, the bulge was slightly asymmetric to the left. There was no evidence of spinal stenosis. In January 1996 the VA MRI showed that there was no nerve root pressure and some diffuse disc bulge and in February 1996 there was some tenderness over the L5 and S1. The assessment was diffuse disc bulge. In November 1997 the impression was spondylitic changes of the lumbosacral spine at L1-2, L5-S1 as well as L4-5. X-rays of the veteran's lumbar spine were done in March 1997, August 1997, June 1998 and March 1999. In March 1997 an imbalance of the pelvis with a 1/2 inch deficiency of the left ilium was shown and there was also moderate degenerative changes noted as well as decreased disc space at L5/S2 level. In August 1997 the impression was mild degenerative spondylosis of the lower lumbar vertebral bodies without significant arthritic changes. In June 1998 there were mild facet joint degeneration at the L4-5 level and mild generalized degenerative change. In March 1999 there were multiple areas of markedly abnormal radiotracer uptake within the spine, especially in the region of the sacrum and lower lumbar spine. The MRI and X-ray findings revealed spondylitic changes of the lumbosacral spine at L1-2, L5-S1 as well as L4-5, and mild facet joint degeneration at the L4-5 level and mild generalized degenerative change. However, the objective findings of record do not reflect a "listing of the whole spine to opposite side or other clinical findings that substantially meet the criteria for a higher disability rating under diagnostic code 5295. See 38 C.F.R. § 4.71, Diagnostic Code 5295 (1999). Forward flexion was 50 degrees in March 1997, 60 degrees in September 1998 and October 1999. Extension was 20 degrees in March 1997, 10 degrees in September 1998, and 35 degrees in October 1999. Lateral bending was 30 degrees in September 1995, September 1998 and October 1999 and 25 degrees in March 1997. The normal ranges of lumbosacral spine motion, according to VA guideline is flexion to 95 degrees; extension to 35 degrees; and lateral flexion to 40 degrees. The veteran's ranges of motion as compared to the normal ranges of motion were moderate. A higher evaluation under diagnostic code 5292 is not warranted. Based on the above findings, and with consideration of the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59, the Board finds that the criteria for an increased rating are not met. Although the veteran reports constant back pain and there is evidence of limitation of motion, he is capable of performing the normal working movements of the back, there is no evidence of weakness. Also, the Board observes that a higher disability rating is not available by evaluating the veteran's back condition under another diagnostic code as there is no evidence of ankylosis, severe limitation of motion, or severe or pronounced intervertebral syndrome. See 38 C.F.R. § 4.71a, Diagnostic Code 5286-5293 (1999). The Board notes that the provision of 38 C.F.R. § 3.102 is not for application in this case as there is not an approximate balance of the positive and negative evidence, which does not satisfactorily prove or disprove the claim, for the reasons discussed above. II. Individual Unemployability Service connection has been established for a fractured left femur with knee injury and chondromalacia rated as 20 percent disabling; chronic low back strain rated as 20 percent disabling; duodenal ulcer rated as 10 percent disabling; disfiguring facial scars rated as 10 percent disabling; left ulnar nerve neuropathy (minor) rated as 10 percent disabling; and status post jaw injury with a 30 percent loss of mandible rated as 10 percent disabling. The combined disability rating is 60 percent. The veteran contends that he is unable to obtain or retain gainful employment due to service-connected disability. In support of this claim, the following evidence was received. Received in August 1997, VA form 21-8940 reflects that the veteran worked from 1991 to 1993 in condominium management; from 1991 to 1994 as a part time night security officer and June 1993 to 1995 as an agent property manager. He last worked in June 1997, he was self- employed doing odd jobs. The VA medical records show that the veteran underwent oral surgery in August 1996. The diagnosis was impaction/multiple periodontal disease. He was seen in the dental clinic from September 1996 to December 1997. In September 1996 the veteran had a small area on the interior mandible which needed to be trimmed and this was performed. Denture impressions were also made. In November 1996 final impressions were performed. The veteran was seen in December 1996 for problems in his left mandibular posterior. There were no signs of drainage on manipulation. No swelling and no sign of exophytic granulation tissue were noted. There was no tenderness to palpation and no trismus. There was no sign of foreign body entrapment into the site. Wax verification was performed, adjustments were performed and a clinical remount was performed. In February 1997 the VA made adjustments to the overextension in the right maxillary retrozygomatic flange area and repolished. Insertion was performed to the realigned dentures. Adjustments were made to the labial ridge and the left posterior flange length in March 1997. Adjustments on the intaglio denture surface were also made. Rough areas were repolished. In May 1997 the VA afforded the veteran a dental examination. His upper and lower dentures appeared to be slightly loose but he was being followed by the prosthodontics in the Dental Service. There were scars in the upper lip and midline the lower lip. His range of motion was normal. Lateral excursive movements were normal as far as functioning of his temporomandibular joint. The residual bone basis over which the dentures were constructed was smooth. The upper and lower dentures were easily removed with minimal pressure indicating perhaps that the veteran could benefit from a reline procedure to enhance denture stability. The VA medical records show that laser destruction of lesions over the right lip commissure was performed in June 1997. Later in the month the veteran was seen for bilateral angular cheilitis. The examiner suspected vertical problems with his dentures. In August 1997 the veteran's dentures had lost some retention and stability due to tissue changes subsequent to oral surgery and natural resorption of the alveolus. Relines of both prostheses were indicated. The occlusion was verified. In October 1997 the veteran was seen for assessment of angular cheilitis of the lips. He began increase of vitamin C intake. The veteran's dentures were adjusted in December 1997. His mandibular was realigned. In July 1998 the veteran's former employer submitted VA Form 21-4192, Request for Employment Information In Connection With Claim for Disability Benefits. The former employer indicated that the veteran's dates of employment were May 1992 to December 1994. The veteran worked part time as a security guard and doorman. The former employer indicated that the reason for termination was that the veteran quit. At the January 1999 Board videoconference the veteran testified that he used to be employed as a heavy equipment operator and that he had done construction work. He stated that later he went into real estate and condominium management and maintenance. The veteran indicated that the walking around and bending became too much. He reported that later he picked up seeds from palm trees for side money and was self-employed subcontracting out landscaping jobs. The veteran testified that he had not worked since 1995. He stated that he attempted many different types of employment including sedentary work but was unable to work because of his low back strain and the pain medications. In March 1999, the veteran was notified that he was awarded disability benefits from the Social Security Administration (SSA). In their favorable decision, SSA noted that the veteran has prostate cancer, not controlled by prescribed therapy, herniated nucleus pulposus at L1-2, L4-5, and T11-12 levels with root impingement at L4-5, which were considered severe under the Social Security regulations. The SSA decision further noted that the March 1997 MRI in which multiple small retroperitoneal lymph nodes in the infrarenal paraaortica area were found. The private examiner opined that these findings could represent metastasises. The VA examination reports were considered by the SSA. In the April 1999 SSA disability determination malignant neoplasm of the prostate was listed as the primary diagnosis and degenerative disc disease was the secondary diagnosis. Analysis Total ratings for compensation purposes may be assigned where the combined schedular rating for the veteran's service- connected disability or disabilities is less than 100 percent when it is found that the service-connected disabilities are sufficient to render the veteran unemployable without regard to either his advancing age or the presence of any nonservice-connected disorders. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.340, 3.341 (1999). The provisions of 38 C.F.R. § 4.16(a) (1999), establish, in pertinent part, that: Total disability ratings for compensation may be assigned, where the schedular rating is less than the total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities: Provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. For the above purpose of one 60 percent disability, or one 40 percent disability disabilities resulting from common etiology or a single accident will be considered as one disability. 38 C.F.R. § 4.16(a)(2) (1999). Service connection has been established for a fractured left femur with knee injury and chondromalacia rated as 20 percent disabling; chronic low back strain rated as 20 percent disabling; duodenal ulcer rated as 10 percent disabling; disfiguring facial scars rated as 10 percent disabling; left ulnar nerve neuropathy (minor) rated as 10 percent disabling; and status post jaw injury with a 30 percent loss of mandible rated as 10 percent disabling. The combined disability rating is 60 percent. The veteran's service-connected disabilities were incurred in a line-of-duty automobile accident. The disabilities resulted from a common etiology or a single accident and will be considered as one disability. Thus, for purposes of determining entitlement to individual unemployability due to service-connected disability, the veteran is considered to have one disability evaluation of 60 percent. 38 C.F.R. § 4.16(a)(2) (1999). The schedular requirements have been met in this case as the veteran's has disabilities will be considered as one disability and are evaluated as 60 percent disabling. A total rating for compensation purposes based upon individual unemployability will be assigned "when there is present any impairment in mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." 38 C.F.R. § 3.340(a). The Board must also give "full consideration... to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effect of combinations of disability." 38 C.F.R. § 4.15 (1999). Consideration may be given to the veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to the appellant's age or impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Moreover, the fact that the veteran is unemployed generally is insufficient to demonstrate that he is "unemployable" within the meaning of the pertinent laws and regulations. A thorough, longitudinal review of all the evidence is necessary to obtain a full understanding of the case. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). While the veteran meets the required disability percentage ratings set forth in 38 C.F.R. 4.16(a)(2), the Board must determine whether the veteran is unemployable as a result of service-connected disability. Having reviewed the record, the Board finds that the preponderance of the evidence is against a finding that the veteran is unemployable as a result of his service-connected disabilities. The evidence shows that the veteran is 49 years old and completed high school. He worked from 1991 to 1993 in condominium management; from 1991 to 1994 as a part time night security officer and June 1993 to 1995 as an agent property manager. He last worked in June 1997; he was self- employed doing odd jobs. Medical evidence shows that the veteran has a fractured left femur with knee injury and chondromalacia, chronic low back strain, duodenal ulcer, disfiguring facial scars, left ulnar nerve neuropathy (minor), residuals of a jaw injury. The VA October 1999 examination conclusion was that the veteran had significant discomfort and loss of function of his back with weakness in is left lower extremity and radicular symptoms. Nevertheless, no medical professional, VA or private, has stated that any service-connected disability of the veteran renders him unemployable. SSA considered the veteran's herniated nucleus pulposus at L1-2, L4-5, and T11-12 levels with root impingement at L4-5 to be severe. However, the award of SSA benefits was primarily based on the diagnosis of malignant neoplasm of the prostate, which is not a service- connected disability. Thus, the record indicates that while the veteran is now considered unemployable, his inability to work stems from impairment caused by nonservice-connected disability, malignant neoplasm of the prostate. Thus, there is no evidence, which suggests that the veteran's industrial impairment is related to, or the product of a service- connected disability. As such, a grant of a total rating based on individual unemployability is not warranted in this instance, as the evidence does not indicate that the veteran is unemployable solely as a result of his service-connected a fractured left femur with knee injury and chondromalacia, chronic low back strain, duodenal ulcer, disfiguring facial scars, left ulnar nerve neuropathy (minor), and residuals of a jaw injury. Accordingly, the Board finds that entitlement to a total rating based on individual unemployability due to service- connected disability is not warranted, and the veteran's claim is denied. In reaching this conclusion, the Board has considered 38 C.F.R. §§ 3.321(b) and 4.16(b), which provide that, to accord justice to the exceptional case where the schedular evaluations are found to be inadequate, an extraschedular evaluation commensurate with the average earning capacity due exclusively to the service-connected disability or disabilities may be assigned. The governing norm of these exceptional cases is a finding that the case presented such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of regular schedular standards. ORDER An increased rating for chronic low back strain is denied. Entitlement to a total rating based on individual unemployability due to service-connected disability is denied. C. P. RUSSELL Member, Board of Veterans' Appeals - 19 - - 1 -