Citation Nr: 0320427 Decision Date: 08/15/03 Archive Date: 08/25/03 DOCKET NO. 94-33 056 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for residuals of a cervical spine injury. REPRESENTATION Appellant represented by: Michael E. Wildhaber, Attorney WITNESSES AT HEARINGS ON APPEAL Appellant and a medical consultant ATTORNEY FOR THE BOARD Thomas A. Pluta, Counsel INTRODUCTION The veteran had active service from March 1968 to September 1970. This appeal arises from a July 1993 rating action that denied service connection for residuals of a cervical spine injury. A Notice of Disagreement was received in September 1993, and a Statement of the Case (SOC) was issued in December 1993. A Substantive Appeal was received in June 1994. In October 1994, the veteran and a medical consultant testified at a hearing before a hearing officer at the RO; a transcript of the hearing is of record. A Supplemental SOC (SSOC) was issued in June 1995. In January 1997, the veteran testified at a Board of Veterans Appeals (Board) hearing before the undersigned in Washington, D.C.; a transcript of the hearing is of record. In April 1997, the Board denied service connection for residuals of a cervical spine injury. The veteran appealed the Board's decision to the U..S. Court of Veterans Appeals (known as the U.S. Court of Appeals for Veterans Claims since March 1999) (Court). In July 1998, the appellant and VA Secretary filed a Joint Motion to Vacate and Remand the Board Decision (Joint Motion). By August 1998 Order, the Court granted the Joint Motion, vacated the April 1997 Board decision, and remanded the case to the Board for further action. In February 1999, the Board remanded this case to the RO for further development of the evidence and for due process development. SSOCs were issued in January and June 2001. In March 2002, the Board again remanded this case to the RO for further development of the evidence and for due process development. A SSOC was issued in September 2002, and the case was returned to the Board for further appellate consideration. In June 2003, the veteran's representative submitted additional evidence and written argument to the Board, and waived, on the veteran's behalf, his right to have the RO initially consider that evidence. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim on appeal has been accomplished. 2. The preponderance of the competent, probative medical evidence of record establishes that the veteran's cervical spine disability, to include arthritis, had its onset many years post service, and is unrelated to either an inservice helicopter accident or the service- connected compression fracture of the dorsal spine. CONCLUSION OF LAW The criteria for service connection for residuals of a cervical spine injury have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist At the outset, the Board notes that, during the pendency of this appeal, the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), was signed into law. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West Supp. 2002). This liberalizing law is applicable to this appeal. See Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). To implement the provisions of the law, VA promulgated regulations published at 66 Fed. Reg. 45,620 (Aug. 29, 2001) (codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2002)). The VCAA and its implementing regulations essentially eliminate the concept of the well-grounded claim. 38 U.S.C.A. § 5107(a); 38 C.F.R. § 3.102. They also include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim (38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b)), as well as the duty to notify the claimant what evidence will be obtained by whom (38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(b)). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)). Having considered the record in light of the duties imposed by the VCAA and its implementing regulations, the Board finds that all notification and development action needed to fairly adjudicate the claim on appeal has been accomplished. In the July 1993 rating action, the December 1993 SOC, the October and December 1994 RO letters, the June 1995 SSOC, the April 1997 Board decision, the February 1999 Board Remand, the June 1999, February 2000, and March 2001 RO letters, the January and June 2001 SSOCs, the March 2002 Board Remand, the March 2002 RO letter, the September 2002 SSOC, and the December 2002 RO letter, the veteran and his representative were variously notified of the law and regulations governing entitlement to the benefit he seeks, the evidence that would substantiate his claim, and the evidence that had been considered in connection with his appeal. Thus, the Board finds that he has received sufficient notice of the information and evidence needed to support his claim, and been provided ample opportunity to submit information and evidence. Additionally, the Board notes that in the aforementioned documents, the RO and the Board variously and specifically informed the veteran and his representative of the VCAA and the implementing VA regulations; what the evidence had to show to establish entitlement to the benefit he sought; what information or evidence VA still needed from the veteran; what evidence VA had retrieved and considered in his claim; what evidence he had to furnish; what he had to do to obtain assistance from VA in connection with his appeal; and that VA would make reasonable efforts to help him get evidence necessary to support his claim, such as medical records, if he gave it enough information about such records so that it could request them from the person or agency that had them. This various correspondence also notified the veteran that VA needed him to furnish the name and address of any medical provider, the time frame covered by the records, and the condition for which he was treated, and that VA would request such records on his behalf if he signed a release authorizing it to request them. The veteran has been variously notified by the RO that he could help with his claim by informing VA of any additional information or evidence that he wanted it to try to obtain for him, where to send additional evidence or information concerning his appeal, and where he could request assistance if needed. Accordingly, the Board finds that the statutory and regulatory requirement that VA notify a claimant what evidence, if any, will be obtained by the claimant and what evidence, if any, will be retrieved by VA also has been met. See Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(b)). The Board also finds that all necessary development has been accomplished. The RO, both on its own initiative and pursuant to the Board's remands, has made appropriate efforts to assist the veteran in attempting to obtain evidence necessary to substantiate his claim. The veteran has testified at a RO hearing in October 1994 and a Board hearing in January 1997. The veteran's representative has submitted private medical records, and the RO has obtained extensive VA and private medical records of treatment and evaluation of the veteran; all have been associated with the claims file. The veteran was afforded comprehensive VA examinations in November 1994, June 1999, and August 2002. In September 2002, the veteran and his representative argued that the August 2002 VA examination was inadequate, and requested a new VA examination by another physician at another VA medical facility. They asserted that the 2002 VA examination was not conducted in a fair, objective, and professional manner by a physician who had not previously examined the veteran, in that the physician who examined the veteran in June 1999 was also present during the examination by the different 2002 VA examiner. Appellate review of the August 2002 VA examination report discloses that it was performed by a physician other than the one who examined the veteran in 1999; that the examiner reviewed the claims file and the March 2002 Board Remand prior to the examination; and that it contains a review of the veteran's medical history, current clinical findings and diagnoses pertaining to the cervical spine, and the examiner's opinions as to the etiology of the current cervical spine disorder, which opinions reflect consideration and specific discussion of all pertinent medical evidence and events reflected in the record, and address other contrary medical opinions of record. Moreover, there is no indication that the examination was conducted in other than a fair, objective, and professional manner, and the Board notes that the examination report properly addressed the matters referred to in the March 2002 Board Remand. Under the circumstances, the Board finds that the August 2002 VA examination, together with the other objective evidence of record, is adequate to equitably adjudicate this claim, and that another VA examination is not necessary. Significantly, the veteran has not identified, and the claims file does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. In an April 2002 letter, the manager of the Gonstead Chiropractic Clinic stated that all clinical records pertaining to the veteran had been released to him, and that he was in possession of 1975 X-rays taken at the clinic. In response to the RO's December 2002 letter soliciting additional evidence, the veteran's representative stated in February 2003 that the veteran had nothing to add to his appeal. Under these circumstances, the Board finds that adjudication of the claim on appeal, at this juncture, without directing or accomplishing any additional notification and/or development action, poses no risk of prejudice to the veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). The claim is ready to be considered on the merits. II. Background A review of the service medical records discloses that the veteran was seen with a 1-day history of back trouble in early November 1969. Current examination showed right paraspinal muscle spasm with resultant right scoliosis. There was no history of trauma. There was no radiating pain, which was localized at L-3. A week later, the veteran was seen with complaints of low back and thoracic spinal pain following an aircraft accident. Current orthopedic examination and X-rays were negative. The neck and spine were normal on September 1970 separation examination. Post service, on May 1971 VA examination of the neck and spine, there was no abnormality of the neck, and the veteran accomplished all motions without difficulty. He could touch his toes. In a statement of July 1974, the veteran stated that he had been unable to report for a VA examination scheduled in April 1974 because he had been in a motorcycle accident. On December 1978 examination by a private chiropractor, the veteran complained of neck pain and stiffness and back pain. Current cervical spine X-rays revealed cervical hypolordosis. There was transverse hypertrophy at C-6 on the right, and right cervical thoracic scoliosis. The diagnosis was chronic paraspinal myofascitis, and neuralgia of the thoracic and lumbar spine. By rating action of October 1979, the RO granted service connection for a compression fracture of the dorsal spine as a residual of an inservice back injury during a helicopter accident. 1982 private chiropractic records show that the veteran was seen after he rolled-over his motor vehicle and his head struck the windshield. He complained of pain and difficult motion of the neck and low back. September 1991 VA outpatient records indicated the veteran's 2-month history of neck pain. Current cervical spine X-rays revealed marked degenerative joint and disc disease at the C4-C5 level with abnormality of the curvature in this area. No acute pathology was noted. On October 1991 VA orthopedic examination, the veteran's complaints included neck and back pain. There were no findings pertaining to the cervical spine. In an October 1991 statement, B. Tosky, a chiropractor, stated that he first saw the veteran in April 1991 for treatment of injuries sustained in a March 1991 automobile accident, the chief symptoms of which included severe head and upper back pain, a stiff and painful neck, and mid-back pain. X-rays revealed posterior ligamentous injury to several cervical vertebra, complete loss of the normal cervical lordotic curve, and osteophytic degeneration of the C-4 vertebra with C-4 disc degeneration. The diagnosis was moderate hyperflexion (whiplash) injury/sprain to the cervical spine, complicated by irritation to the C-3, 4, 5, and 6 nerve roots along with paravertebral muscle spasm. On December 1991 VA outpatient orthopedic examination, the veteran was noted to have sustained a compression fracture in a helicopter crash, and to have been re-injured in a 2-car automobile crash. Current X-rays revealed a fairly normal cervical spine (interspaces, vertebral height, etc.), which was straightened. In a March 1992 statement, Mr. Tosky stated that he had reviewed 1972 (sic) X-rays and that the veteran had sustained an intensely traumatic injury to his cervical spine. He opined that the loss of the normal lordotic curve was consistent with what was seen in a severe acceleration- deceleration injury such as a fall, and that the misalignment of atlas or axis was also symptomatic of such forceful cervical sprain. In February 1994, the veteran was hospitalized at the North Carolina Baptist Hospital for treatment of a Type II odontoid fracture sustained in a motor vehicle accident a few days ago. A history of a motor vehicle accident 3 years ago with neck sprain was noted, with no residuals. During his hospital course, surgery was performed to internally fix the odontoid fracture. X-rays of the cervical spine revealed loss of disc space, end plate sclerosis, and osteophyte formation at the C4-5 level. There was straightening of the normal cervical lordosis. The veteran was discharged from the hospital in stable condition. At the October 1994 RO hearing, the veteran testified that he currently suffered from a cervical spine disorder as a result of compression of cervical vertebra incurred during a helicopter accident in service in 1969, and that his contentions were supported by competent medical opinions. On November 1994 VA orthopedic examination, the veteran gave a history of a crushed vertebra in his neck after a helicopter crash in 1969. After further questioning of the veteran, the examiner felt that the fracture involved the veteran's thoracic spine, not the neck. Current cervical spine X-rays revealed two bone screws in the midline, presumably extending from the bodies of the 2nd cervical vertebra into the 1st. There was evidence of narrowing of the C4-5 intervertebral disc space with marginal spurring, compatible with disc pathology. After examination, the diagnoses were status post fracture of the dorsal spine anterior wedge without neurological deficit by history, secondary to helicopter accident; and history of cervical spine degenerative arthritis with no evidence of significant limitation of range of motion or neurological deficit. After careful review of the veteran's file, the examiner opined that the veteran's cervical spine pathology was not related to the injury he sustained to the thoracic spine, at which time an anterior wedge compression fracture occurred, and which thoracic spine disorder was service connected. In a January 1995 statement, W. Cox, a chiropractor, stated that, after comparing the veteran's February 1994 X-rays with those of January 1975, he found that the veteran's neck condition had worsened dramatically, with increased kyphosis and bone and disc degeneration. Mr. Cox opined that the cause of the veteran's condition was a 1969 inservice helicopter accident and the injuries suffered at that time. In a May 1995 addendum to the November 1994 VA examination report, the same VA physician stated that he had reviewed the veteran's claims file and undated cervical spine X-rays from a chiropractor. VA physician noted that the latter X-rays showed no significant cervical spine pathology. After a careful review of the evidence, VA doctor opined that the veteran's cervical spine pathology was not related to the anterior wedge compression fracture he sustained to the thoracic spine, which disability was service connected. VA examiner also noted 1994 North Carolina Baptist Hospital records indicating that trauma to the veteran's cervical spine occurred in a February 1994 motor vehicle accident, and that he underwent odontoid screw fixation at that time. VA physician concluded that the veteran's cervical spine problem occurred in 1994 and was in no way related to his service- connected injury many years ago. At the January 1997 Board hearing, the veteran testified that he currently suffered from a cervical spine disorder as a result of a helicopter accident in service in 1969, and that his contentions were supported by competent medical opinions. He reported that he re-injured his back and neck in a motor vehicle accident in 1994. On June 1999 VA orthopedic examination, the examiner reviewed the claims file and the February 1999 Board Remand. The veteran gave a history of the onset of his spine disabilities during a 1969 helicopter accident. The examiner noted that the veteran was subsequently found to have had a compression fracture of the 7th thoracic vertebral body, but that his records did not indicate the extent of the examination or any findings related to the neck at that time. The examiner also noted a fracture of the odontoid process of the neck in an automobile accident in February 1994, with operative repair and screw fixation at that time. After current examination and cervical spine X-rays, the diagnoses included post-operative healed odontoid fracture of the cervical spine; history of cervical degenerative disc disease with X-ray changes reported and present on current examination; and healed, asymptomatic compression fracture of the 7th thoracic vertebral body. The examiner opined that it was not likely that the current cervical spine findings were related to the veteran's military service or to his service- connected thoracic spine disorder, or that the service- connected thoracic compression fracture aggravated any current cervical symptoms. The reason for these conclusions was that there was no report of complaints and/or examinations to any extent of any severity of cervical injury in the veteran's inservice helicopter crash which would be likely to be manifest by the present findings many years later. The examiner noted that the injury to the cervical odontoid process clearly occurred in a later motor vehicle accident. Although there was some possibility that cervical degenerative disc problems could have started during the veteran's military service, the doctor did not believe that there was any evidence of record to sustain such an opinion, noting that the degree of cervical degeneration seen in the veteran was as often as not seen in middle-aged men without the history of any antecedent severe injury. In an April 2000 addendum to the June 1999 VA examination report, the same VA physician stated that he had reviewed additional medical evidence that had been introduced into the veteran's claims file subsequent to the latter 1999 examination, as well as other records in the claims file, and that the additional evidence did not alter the diagnoses or opinions expressed in the 1999 report. In a May 2001 statement, C. Bash, M.D., stated that he had reviewed the veteran's claims file including the service and post-service medical records, VA rating actions, SOC, and SSOCs, the veteran's hearing testimony, VA examination reports, and medical literature, and opined that the veteran's inservice cervical spine injury in a helicopter crash caused his current cervical spine pathology, advanced degenerative arthritis. Dr. Bash disagreed with the May 1995 VA examiner's opinion, on the grounds that the veteran clearly had a pre-1994 cervical spine injury and disability, citing Mr. Tosky's March 1992 report. Dr. Bash noted that the veteran's current cervical spine problems were located in the lower spine, with the most severe disease at the C4-5 level, whereas the 1994 accident caused a fracture at a different level, i.e., the odontoid, located at the C-2 level. Dr. Bash further noted that the May 1995 VA examiner failed to comment about the clinical findings pertaining to the neck on a December 1978 examination, in Mr. Tosky's March 1992 report, and in Mr. Cox's January 1995 report. To the contrary, Dr. Bash opined that it was clear from the record that the veteran sustained a severe spine injury in the 1969 helicopter crash, and that his whole spine was affected by this crash, as it was an axial-type load that caused the thoracic spine fracture which was not initially diagnosed by military medical authorities. In support of this opinion, Dr. Bash quoted from medical literature, to the effect that injuries to the spine early in life lead to advanced spine degenerative disease; at the onset, tearing of ligaments and subluxation are manifest by local symptoms of back pain accentuated by the motion which stretches the ligaments, and eventually symptoms of localized degenerative arthritis are superimposed. Dr. Bash further opined that the veteran's current cervical spine problems were caused by his inservice helicopter crash with spine injury, and stated that this opinion was based on the 1978 cervical spine X-ray findings, the mechanism of injury, medical assessments, and the veteran's testimony, and was in agreement with both chiropractic opinions of Mr. Tosky and Mr. Cox. Dr. Bash stated that he discounted the May 1995 VA examiner's opinion because he did not think that VA physician fully reviewed the record, and he felt that VA physician missed some very pertinent facts, and did not comment on the Tosky or Cox chiropractic opinions or the evidence of the veteran's cervical spine injury prior to 1994. On August 2002 VA orthopedic examination, the physician stated that he reviewed the veteran's claims file and the March 2002 Board Remand prior to examining the veteran. The examiner reviewed the veteran's military and medical history, including a late-1960s helicopter accident, the mid-1970s finding of a compression fracture of the 7th thoracic vertebral body, chiropractic treatment since the mid-1970s, and a fracture of the cervical spine odontoid process in a February 1994 automobile accident. VA examiner noted a chiropractor's opinion that 1970s cervical spine X-rays showed degenerative changes, but that after a current review of those 1975 X-rays [the Board notes that the veteran brought to the current examination the original X-rays of his cervical spine taken at the Gonstead Chiropractic Clinic in January 1975], a VA radiologist saw no such changes. The radiologist noted that 1979 VA X-rays showed a compression fracture at the T-7 level, and 1994 VA X-rays clearly showed cervical degenerative changes. After current examination, the diagnoses were thoracic spine degenerative joint disease; status post T-7 fracture with residuals; and status post fracture of the odontoid process of C-2 with degenerative changes of the neck. VA physician opined that the veteran's cervical spine disease was not caused by the late 1960s helicopter accident, or caused or aggravated by the dorsal spine fracture. This reason for this conclusion was that a current VA radiologist's review of 1975 X-rays showed no evidence of any cervical degenerative changes therein. VA examiner noted that this opinion was in disagreement with Dr. Bash's opinion and Mr. Cox's chiropractic report, and he could not explain why the latter 2 individuals saw degenerative changes in 1975 where a VA physician/radiologist saw none. As a result, VA physician concluded that there was no evidence that the inservice helicopter accident, which resulted in the veteran's thoracic spine problem, resulted in any way in his cervical spine problems. In a June 2003 statement, Dr. Bash stated that he re-reviewed the veteran's medical records in this case, to include 1975, 1994, and 2001 X-rays and the August 2002 VA orthopedic examination report, and opined that the veteran's 1969 inservice helicopter accident injured his cervical spine and led to degenerative change therein, and that these changes had worsened over time and caused his current neurologic signs and symptoms. He asserted that this opinion was consistent with those of Messrs. Cox and Tosky, and that nothing in the medical record since his last review would alter that opinion. After reviewing January 1975 X-rays of the veteran's cervical spine, Dr. Bash agreed with the August 2002 VA radiologist's opinion that they showed no significant bony changes. He also opined that the longstanding, slowly progressive degenerative changes at the C4-5 level shown on 1994 X-rays were caused by the veteran's 1969 inservice helicopter accident, as those type of changes could absolutely not have been initially caused by an acute 1994 automobile accident, because the time interval was too short. He also opined that the C-4-5 pathology also could not have been caused by the veteran's 1974 motorcycle accident, because he only injured his leg therein. Dr. Bash discounted the probative value of the August 2002 VA examiner's opinions because he was not a radiologist himself, and because he relied upon the opinion of an unnamed radiologist who failed to provide a written report for the record and comment on the significance of the veteran's C4-5 degenerative changes, on how those changes were likely developed, on what likely caused those changes to occur, and on how those changes related to the negative 1975 X-rays and the veteran's medical history in reaching his conclusions. III. Analysis The veteran contends that he currently suffers from a cervical spine disorder as a result of a helicopter accident in service in 1969. He asserts that his whole spine, including the neck and thoracic spine, were injured at the same time, and that his contentions are supported by competent medical opinions. Under the applicable criteria, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by wartime service. 38 U.S.C.A. § 1110. Where a veteran served continuously for 90 days or more during a period of war, and arthritis becomes manifest to a degree of 10 percent within 1 year from the date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Such a determination requires a finding of a current disability that is related to an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309 (1993); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Additional disability resulting from the aggravation of a non-service-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In this case, the slim evidence in support of the veteran's claim for service connection for residuals of a cervical spine injury includes the veteran's 1994 and 1997 hearing testimony, wherein he expressed his belief that he suffered compression of cervical vertebra in a helicopter accident in service, and that he currently suffered residual disability from this; Mr. Cox's January 1995 chiropractic opinion which appears to have no medical or factual basis; and Dr. Bash's May 2001 and June 2003 medical reports which are based upon an inaccurate factual basis, and contain medical conclusions that are not supported by the actual facts in this case. With respect to the veteran's testimony, the Board observes that, as a layman without the appropriate medical training and expertise, he is not competent to render a probative opinion on a medical matter-such as the date of onset of medical disorders, and whether there is a medical relationship between a current disability and an incident of his military service. See Bostain v. West, 11 Vet. App. 124, 127 (1998), citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) (a layman is generally not capable of opining on matters requiring medical knowledge). With respect to Mr. Cox's 1995 chiropractic statement, the Board observes that there is no medical or factual basis in that statement to support his conclusion that the cause of the veteran's current cervical spine disorder was injury in a 1969 inservice helicopter accident. Rather, that statement appears to be based on pure speculation. Significantly, Mr. Cox does not state that the 1975 X-rays revealed any cervical spine disability at that time. Although he does state that the veteran's cervical spine disorder deteriorated between 1975 and 1994, this mere post-service medical fact does not support the inservice onset of any cervical spine disability, or otherwise indicate a basis for relating the current cervical spine disorder to military service or any incident thereof. With respect to Dr. Bash's 2001 and 2003 medical reports, the Board observes that they are based upon an inaccurate factual basis, and contain medical conclusions that are not supported by the actual facts in this case. First, there is no evidence to support the opinion that the veteran injured his cervical spine in the 1969 inservice helicopter accident. In fact, the service and post-service medical records are completely negative for any cervical spine pathology until December 1978, over 4 years following separation from service, and the 1978 findings contain no evidence linking the cervical pathology demonstrated at that time to the veteran's military service or any incident thereof. In fact, the service medical records show only complaints restricted to the low back and thoracic spine following the aircraft accident, and no cervical spine pathology was thereafter objectively demonstrated on September 1970 separation examination, May 1971 VA examination, and January 1975 cervical X-rays (as interpreted by a VA radiologist in August 2002). Second, Dr. Bash relies upon Mr. Tosky's March 1992 chiropractic report in support of his conclusion relating the veteran's current cervical spine disorder to military service. The Board finds Dr. Bash's reliance misplaced, as there is nothing in the March 1992 report to support such etiology of the veteran's cervical spine pathology. Close review of the latter statement does not show that the reference to a review of 1972 (sic) X-rays has anything to do with the fact that the veteran had sustained an intensely traumatic injury to his cervical spine, including loss of the normal lordotic curve and a severe acceleration-deceleration injury and forceful cervical sprain. Nowhere in his 1992 report does Mr. Tosky relate the veteran's current cervical spine pathology to military service or any incident thereof. Rather, the Board finds that the 1992 report is more accurately read in the context of Mr. Tosky's previous October 1991 medical report, wherein he relates the veteran's significant April 1991 cervical spine pathology, including complete loss of the normal cervical lordotic curve and osteophytic degeneration of the C-4 vertebra with C-4 disc degeneration, to a hyperflexion (whiplash) injury/sprain sustained in a recent March 1991 automobile accident. This would also explain Mr. Tosky's 1992 reference to a severe acceleration-deceleration injury and forceful cervical sprain. Third, Dr. Bash, in his 2001 and 2003 reports, did not make reference to important September 1991 VA X-rays showing significant C4-5 pathology and Mr. Tosky's October 1991 report of existant cervical spine pathology related to a March 1991 automobile accident, thereby missing very pertinent facts in any determination of the etiology of the veteran's cervical spine pathology. While Dr. Bash states that the cervical pathology demonstrated on 1994 X-rays could not have been the result of the acute 1994 automobile accident, this fact does not serve as a logical basis for then relating that pathology to the 1969 inservice helicopter accident, in the absence of reference to the significant 1991 intercurrent trauma. Dr. Bash's omission of reference to the pertinent 1991 medical records showing significant cervical pathology related to an intercurrent March 1991 automobile accident shows that he did not have the veteran's entire documented medical history for review in reaching his conclusions, as a result of which the Board finds them of little probative value. Although the Board finds Dr. Bash's determination that it was clear from the record that the veteran sustained a severe spine injury in the 1969 inservice helicopter accident to be supported by the facts - the veteran is in fact service connected for a compression fracture of the dorsal spine as a residual of an inservice back injury during a helicopter accident - there is no factual basis beyond pure speculation to support his conclusion that the veteran's whole spine was affected by this accident, particularly in light of the factual record showing no cervical spine pathology in service and for several years thereafter, and the veteran's involvement in 4 separate intercurrent motor vehicle accidents in the post-service years in 1974, 1982, 1991, and 1994 - 3 of which (1982, 1991, and 1994) are documented to have specifically involved injury to the cervical spine. Furthermore, the Board finds Dr. Bash's reliance on the 1978 cervical X-ray findings to support his opinion that the veteran's current cervical spine problems were caused by his inservice helicopter crash with spine injury to be misplaced, inasmuch as the 1978 findings, as noted above, contain no evidence linking the cervical pathology demonstrated at that time to the veteran's military service or any incident thereof. The Board finds that the clear preponderance of the evidence in this case is against the veteran's claim for service connection for residuals of a cervical spine injury. Specifically, the negative evidence against the claim includes the service medical records, which confirm a 1969 aircraft accident with involvement of the thoracic spine, but are completely negative for involvement of the cervical spine. When cervical spine pathology was first objectively demonstrated in the 1978 chiropractic examination report, over 4 years post service, there was nothing therein to relate it to the veteran's military service or any incident thereof, including the 1969 aircraft accident. Nothing in the September 1991 VA radiographic report related the marked degenerative joint and disc disease at the C4-5 level to military service or any incident thereof. As noted above, Mr. Tosky's October 1991 chiropractic report related the veteran's cervical pathology to a recent automobile accident, not any incident of his military service. 1994 North Carolina Baptist Hospital records show surgical treatment of the veteran's cervical spine following a motor vehicle accident. Following November 1994 VA orthopedic examination, the examiner opined that the veteran's cervical spine pathology was not related to the injury he sustained to the thoracic spine in service, at which time an anterior wedge compression fracture occurred, and which thoracic spine disorder was service connected; the physician reiterated that opinion in May 1995 following review of additional evidence, and further concluded that the veteran's cervical spine problem had its onset many years post service and was in no way related to his inservice injury. As noted above, there is no medical or factual basis in Mr. Cox's January 1995 chiropractic statement to support his conclusion that the cause of the veteran's current cervical spine disorder was injury in a 1969 inservice helicopter accident; rather, that statement appears to be based on pure speculation. Following June 1999 VA orthopedic examination, the examiner opined that it was not likely that the current cervical spine findings were related to the veteran's military service or to his service-connected thoracic spine disorder, or that the service-connected thoracic compression fracture aggravated any current cervical symptoms; although there was some possibility that cervical degenerative disc problems could have started during the veteran's military service, the doctor did not believe that there was any evidence of record to sustain such an opinion, noting that the degree of cervical degeneration seen in the veteran was as often as not seen in middle-aged men without the history of any antecedent severe injury. The latter VA physician's April 2000 review of additional medical evidence, as well as other records in the claims file, resulted in no alteration of the diagnoses or opinions expressed in the 1999 report. The Board finds of particular probative value the August 2002 VA orthopedic medical opinions, to the effect that the veteran's cervical spine disease was not caused by the inservice helicopter accident, or caused or aggravated by the service-connected dorsal spine fracture. These opinions were rendered by a physician who reviewed the entire claims file, the March 2002 Board Remand, and the veteran's entire medical history; currently examined the veteran and recorded clinical findings and diagnoses pertaining to the cervical spine; and reached his conclusions as to the etiology of the veteran's current cervical spine disorder based on consideration and specific discussion of all pertinent medical evidence and events reflected in the record, including original 1975 chiropractic X-rays of the veteran's cervical spine which were reviewed by a radiologist. Moreover, the VA physician addressed and convincingly disposed of Dr. Bash's and Mr. Cox's contrary opinions of record, as well as thoroughly addressed the matters referred to in the March 2002 Board remand. Thus, the Board finds that the August 2002 VA examination report plays a decisive role in the disposition of the issue on appeal. For all the foregoing reasons, the claim for service connection for residuals of a cervical spine injury must be denied on a direct service incurrence and presumptive basis, as well as on a secondary basis (i.e., as secondary to the service-connected compression fracture of the dorsal spine, to include by way of aggravation as provided by Allen). In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the competent medical evidence neither supports, nor is in relative equipoise with respect to, the claim, that doctrine is not for application in this appeal. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Service connection for residuals of a cervical spine injury is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.