Citation Nr: 0810573 Decision Date: 03/31/08 Archive Date: 04/09/08 DOCKET NO. 06-10 369 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to a rating in excess of 20 percent for traumatic arthritis and degenerative disc disease of the cervical spine, with a history of neuritis. REPRESENTATION Appellant represented by: Mississippi Veterans Affairs Commission ATTORNEY FOR THE BOARD Nicole Klassen, Associate Counsel INTRODUCTION The veteran served on active duty from September 1988 to March 1989 and from September 1989 to June 1995. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson Mississippi, which denied the above claim. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The veteran injured his neck in an in-service car accident in 1992. His disability of the cervical spine is currently rated at 20 percent disabling. He contends that his disability is worse than it is currently rated. The veteran underwent a VA examination in July 2005, at which time the examiner reported a 6 centimeter by 6 centimeter area overlying the left trapezius, to the left of the T1, where there was decreased sensation to a pinprick. The examiner noted that, based on magnetic resonance imaging (MRI) results, it appeared that the veteran had cervical disc disease with radiculopathy and myelopathy. Although radiculopathy and myelopathy were noted, there is no evidence of record that the veteran has been afforded a proper neurological examination to determine the extent of these manifestations. Such an examination should be provided to the veteran before the Board renders a decision in this case. Any recent VA treatment records should also be obtained. Additionally, the veteran reported during his July 2005 VA examination that he was receiving treatment from a private doctor and had been undergoing physical therapy. To date, however, the most recent private treatment records associated with the claims file date from November 2002. The veteran should be requested to submit a VA Form 21-4142, Authorization and Release of Information to the Department of Veterans Affairs, for any private doctor(s) that have treated his cervical spine disability. These records should be obtained on remand. In the statement of the case, it was noted that the veteran had been denied Social Security Administration (SSA) benefits. His records from SSA should be obtained on remand. See Murincsak v. Derwinski, 2 Vet. App. 363 (1992). Finally, since notice that complies with Vasquez-Flores v. Peake, No. 05-0355, 2008 WL 239951 (Ct. Vet. App. January 30, 2008), has not been provided, such notice should be sent to the veteran. Accordingly, the case is REMANDED for the following action: 1. Send the veteran notice that includes an explanation as to the information and evidence needed for an increased rating claim, as outlined in Vasquez-Flores v. Peake, No. 05-0355, 2008 WL 239951(Ct. Vet. App. January 30, 2008). 2. Request the veteran to identify any private medical care providers that have treated his cervical spine disability since July 2004. After obtaining any required authorizations, the RO/AMC should make arrangements to obtain the veteran's complete private treatment records. 3. Make arrangements to obtain a complete copy of the veteran's treatment records for a cervical spine disorder from the Decatur VA Medical Center, dated since November 2005. 4. Make arrangements to obtain from SSA copies of all the documents or evidentiary material that were used in considering the veteran's claim for disability benefits. 5. Thereafter, schedule the veteran for a VA orthopedic/neurological examination. The claims file and a copy of this remand should be made available to and reviewed by the examiner(s) in conjunction with the examination(s). All necessary tests should be conducted. The examiner(s) should identify and describe in detail all residuals attributable to the veteran's service- connected traumatic arthritis and degenerative disc disease of the cervical spine, with a history of neuritis. The examiner(s) should identify any orthopedic and neurological findings related to the service-connected disability and fully describe the extent and severity of those symptoms. The examiner(s) should conduct range of motion testing of the cervical spine. Whether there is any pain, weakened movement, excess fatigability or incoordination on movement should be noted, and whether there is likely to be additional range of motion loss due to any of the following should be addressed: (1) pain on use, including during flare- ups; (2) weakened movement; (3) excess fatigability; or (4) incoordination. The examiner(s) is asked to describe whether pain significantly limits functional ability during flare-ups or when the cervical spine is used repeatedly. All limitation of function must be identified. If there is no pain, no limitation of motion and/or no limitation of function, such facts must be noted in the report(s). With regard to any neurological disability resulting from the service-connected neck disability, the specific nerve(s) affected should be specified, together with the degree of paralysis caused by service- connected disability. The examiner(s) should document the number of weeks, if any, during the past 12 months, that the veteran has had "incapacitating episodes," defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician." The examiner(s) must provide a comprehensive report(s) including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 6. Finally, readjudicate the veteran's claim on appeal. If the claim remains denied, provide the veteran and his representative with a supplemental statement of the case and allow an appropriate time for response. The appellant has the right to submit additional evidence and argument on the matter 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 remanded by the Board of Veterans' Appeals 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 Supp. 2007). _________________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2007).