Citation Nr: 1312236 Decision Date: 04/12/13 Archive Date: 04/19/13 DOCKET NO. 04-13 953 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a cervical spine disability, to include degenerative disc disease and degenerative joint disease, to include as secondary to the service-connected lumbosacral strain with degenerative disc disease L4-L5, L5-S1 with radiculopathy. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD L. Durham, Counsel INTRODUCTION The Veteran served on active duty from September 1974 to April 1980 with additional periods of active duty for training in the Florida National Guard. This appeal comes before the Board of Veterans' Appeals (Board) from a December 2002 rating decision of a VA RO. In July 2008, the Veteran testified at a videoconference before the undersigned Veterans Law Judge (VLJ) at the St. Petersburg, Florida, RO. A transcript of this hearing has been associated with the claims file. The Board notes that, in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ/Decision Review Officer (DRO) who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the Veteran presented testimony concerning why his disability should be service connected and his treatment history. Significantly, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has either identified any prejudice in the conduct of the Board hearing. Moreover, the claim was remanded by the Board on multiple occasions to further develop the evidence. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). In September 2008, the Board remanded this claim for additional development, which included providing the Veteran with a VA examination and having the examiner address the likelihood that cervical spine disease was incurred in service or due to or aggravated by the Veteran's service-connected lumbar spine disability. That examination was completed in October 2008. In July 2010, the Board denied the claim for service connection for cervical disc disease on a direct basis and as being secondary to the service-connected lumbar spine disability. The Veteran appealed the Board's decision to the Court. In July 2011, the Veteran and the Secretary of VA (parties) filed a joint motion to vacate the Board decision and remand it for further development. The Court granted the motion that same month. In December 2011, the Board remanded the claim for additional development and adjudicative action consistent with the joint motion. In October 2012, the case was returned to the Board for further appellate review. The Board remanded this issue for additional development, which included obtaining a medical opinion regarding a possible relationship between the Veteran's cervical spine disability and his service-connected lumbar spine disability. The requested development has been conducted, and the issue has been returned to the Board for further appellate review. The Board has reviewed the Veteran's claims file and the record maintained in the Virtual VA paperless claims processing system. FINDING OF FACT A cervical spine disorder was not shown in service, arthritis was not demonstrated to a compensable degree within one year of discharge from active duty, and the competent medical evidence of record does not show a cervical spine disability to be etiologically related to a disease, injury, or event in service, to include a service-connected disability. CONCLUSION OF LAW A cervical spine disability was not incurred in active military service, may not be presumed to have been incurred in service, and is not proximately due to or the result of any service-connected disability. See 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, and 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the VCAA, the VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court held that, upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, the duty to notify was not satisfied prior to the initial unfavorable decision on the claim by the AOJ. Under such circumstances, VA's duty to notify may not be "satisfied by various post-decisional communications from which a claimant might have been able to infer what evidence the VA found lacking in the claimant's presentation." Rather, such notice errors may instead be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006) (where notice was not provided prior to the AOJ's initial adjudication, this timing problem can be cured by the Board remanding for the issuance of a VCAA notice followed by readjudication of the claim by the AOJ) see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case (SOC) or supplemental statement of the case (SSOC), is sufficient to cure a timing defect). In this case, the VCAA duty to notify was satisfied subsequent to the initial AOJ decision by way of letters sent to the appellant in June 2001, April 2008, and October 2008 that addressed all notice elements. The letters informed the appellant of what evidence was required to substantiate the claim as directly related to service and of the appellant's and VA's respective duties for obtaining evidence. In addition, the February 2004 SOC, the RO provided the Veteran with notice as to the criteria for secondary service connection. Although the SOC and the April 2008 and October 2008 notice letters were not sent before the initial AOJ decision in this matter, the Board finds that this error was not prejudicial to the appellant because the actions taken by VA after providing the notice have essentially cured the error in the timing of notice. Not only has the appellant been afforded a meaningful opportunity to participate effectively in the processing of her or his claim and given ample time to respond, but the AOJ also readjudicated the case by way of a SSOC issued in March 2010 after the notice was provided. The March 2010 SSOC also informed the Veteran of the criteria for secondary service connection and explained why the claim was denied on a secondary basis. Accordingly, a reasonable person would be expected to understand what was required to substantiate the claim on a secondary basis. For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide this appeal, as the timing error did not affect the essential fairness of the adjudication. Additionally, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service treatment records and other pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained VA treatment records and records from the Social Security Administration. The Veteran submitted treatment records from Forts Gordon and Jackson, and Drs. R.G., G.R., R.Z., D.J., J.V., and W.L., and was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4)(i) (2012). The Veteran was provided VA medical opinions with regard to his cervical spine claim in May 2012 and November 2012. The examiner reviewed the claims files, conducted the appropriate tests and studies, and noted the Veteran's assertions. As such, the Board finds these examination reports and opinions to be thorough, complete, and sufficient upon which to base a decision with regard to this claim. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Analysis The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2012). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2012). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to or the result of an established service-connected disability. 38 C.F.R. § 3.310 (2012). This includes disability made chronically worse by service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that there was an amendment to the provisions of 38 C.F.R. § 3.310. See 71 Fed. Reg. 52744 - 47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is judged. Although VA has indicated that the purpose of the regulation was merely to apply the Court's ruling in Allen, it was made clear in the comments to the regulation that the changes were intended to place a burden on the claimant to establish a pre-aggravation baseline level of disability for the nonservice- connected disability before an award of service connection based on aggravation may be made. This had not been VA's practice, which suggests the possibility that the recent change amounts to a substantive change in the regulation. For this reason, and because the Veteran's claim was pending before the regulatory change was made, the Board will consider the version of 38 C.F.R. § 3.310 in effect before the change, which is more favorable to the claimant. Certain diseases, to include arthritis, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C.A. § 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). The term "Veteran" is defined in 38 U.S.C.A. § 101(2) as "a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable." The term "active military, naval, or air service" includes active duty, and "any period of active duty for training during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty." 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a) (2012); Biggins v. Derwinski, 1 Vet. App. 474, 477-478 (1991). Active duty for training (ACDUTRA) is defined, in part, as "full-time duty under sections 316, 502, 503, 504, or 505 of title 32 [U. S. Code] or the prior corresponding provisions of law." 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c). The term inactive duty training (INACDUTRA) is defined, in part, as duty, other than full-time duty, under sections 316, 502, 503, 504, or 505 of title 32 [U. S. Code] or the prior corresponding provisions of law. 38 U.S.C.A. § 101(23); 38 C.F.R. § 3.6(d). Thus, with respect to the Veteran's National Guard service, service connection may only be granted for disability resulting from disease or injury incurred or aggravated while performing ACDUTRA, or an injury incurred or aggravated while performing INACDUTRA. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131; 38 C.F.R. §§ 3.6, 3.303, 3.304. Service connection is generally not legally merited when a disability incurred on INACDUTRA results from a disease process. See Brooks v. Brown, 5 Vet. App. 484, 487 (1993). Certain evidentiary presumptions -- such as the presumption of sound condition at entrance to service, the presumption of aggravation during service of preexisting diseases or injuries which undergo an increase in severity during service, and the presumption of service incurrence for certain diseases, such as arthritis, which manifest themselves to a degree of disability of 10 percent or more within a specified time after separation from service--are provided by law to assist Veterans in establishing service connection for a disability or disabilities. 38 U.S.C.A. §§ 101, 1112; 38 C.F.R. § 3.304(b), 3.306, 3.307, 3.309. However, the advantages of these evidentiary presumptions do not extend to those who claim service connection based on a period of ACDUTRA or INACDUTRA. Paulson v. Brown, 7 Vet. App. 466, 470-71 (1995) (noting that the Board did not err in not applying presumptions of sound condition and aggravation to appellant's claim where he served only on ACDUTRA and had not established any service-connected disabilities from that period); McManaway v. West, 13 Vet. App. 60, 67 (citing Paulson, 7 Vet. App. at 469-70, for the proposition that, "if a claim relates to period of [ACDUTRA], a disability must have manifested itself during that period; otherwise, the period does not qualify as active military service and claimant does not achieve Veteran status for purposes of that claim."). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran seeks entitlement to service connection for cervical disc disease. The Veteran contends that his cervical disc disease is due to injury while on ACDUTRA and/or his service-connected lumbar spine disorder. Service personnel records showed that the Veteran was on ACDUTRA on February 8, 1986. He was assigned to operate a heavy forklift truck on rough terrain throughout the day and was required to manually adjust the lifting forks. The Veteran noted that he had an unusual feeling in his lower back while performing his duty. The next day, the Veteran was treated at a community hospital for urinary bleeding that resolved promptly with medication. The Veteran complained of pain in his lower back. In March 1986, the Veteran was admitted to a naval hospital with symptoms of persistent lower back pain. On examination, the physician noted lumbar paravertebral spasms. X-rays were negative, and there were no neurologic deficits. On March 20, 1986, the Veteran complained of neck pain on the right side. On March 23, 1986, there was a notation of neck discomfort. The Veteran was transferred to another hospital in Fort Gordon, Georgia, on March 30, 1986. The examiner noted that the Veteran had a history of an injury to the lower back on February 8, 1986. On March 30, 1986, physical examination revealed that his neck was supple with full range of motion. Sensory examination revealed no deficit in any dermatome. In June 1986, the attending Navy physician noted that the Veteran had shown no improvement after three months of inpatient treatment and physical therapy. The Veteran was discharged with no additional diagnoses or treatment plan. There were no notations of cervical spine symptoms. In a July 1986 line of duty determination, the Army found no injury in the line of duty. The Veteran appealed and provided a statement in December 1986 that further described the circumstances and symptoms that he experienced since the day of his February 1986 injury. He did not mention any symptoms related to his neck. In correspondence in August 1986, a chiropractor stated that he sporadically treated the Veteran on ten occasions for low back pain starting nine days after the active duty forklift work, and that he diagnosed bulging disc syndrome of the lower spine. He did not note any cervical spine symptoms or diagnose a cervical spine disorder. In January 1987, a private physician stated that the Veteran's back symptoms could be related to a type of injury that one might sustain while operating heavy equipment. In March 1987, the Army found that the Veteran had injured his lower back in the line of duty. In February 1987, a psychiatric examiner noted the Veteran's reports of occasional severe pains in his neck that prevented rotating his head. In February 1987 and May 1988, private orthopedic physicians noted the Veteran's reports of continued back and neck pain. However, both physicians concluded that there was no pathology to support the symptoms, and neither physician diagnosed a cervical spine disorder. In May 1988, the Veteran underwent private treatment for low back pain. The Veteran reported pain in the neck at the base of the skull with a headache. The physician did not report a diagnosis of any cervical disorder. In an October 1996 VA consultation sheet, the Veteran complained of chronic low back pain, as well as chronic neck pain, since a motor vehicle accident in 1986. In October 1996, a VA examiner noted the Veteran's reports of continued chronic back and neck pain. X-rays showed intervertebral narrowing at C3-4 and some loss of lordotic curvature suggesting muscle spasms. The examiner diagnosed osteoarthritis of the cervical spine. In June 1997, the Veteran underwent an X-ray and a magnetic resonance imaging (MRI) scan of the cervical spine. The MRI revealed disc narrowing at C3-4 and some herniation but no nerve compression or stenosis. In March 1999, the Veteran was reported to complain of pain in the neck and headaches. The Veteran indicated that the headaches were relieved by "popping" his neck. In September 1999, the Veteran was diagnosed with cervical disc disease. In October 1999, the Veteran underwent occupational therapy for neck pain. In February 2000, a diagnosis of cervical degenerative joint disease, service-connected, paperwork in progress was provided. In June 2000, a VA neurologist noted that the Veteran reported a sudden onset of numbness in the left arm and neck pain. In September 2000, a VA examiner noted that the Veteran was receiving steroid injections and was prescribed a cervical collar. The remainder of the examination was related to the lumbar spine. In a July 2001 letter, a private chiropractor noted that he had been treating the Veteran for five months for chronic neck pain, radiating to the arms. He referred to VA MRI studies that showed positive indications of spondolytic changes at C3-4 and disc herniation in the lumbar spine. The chiropractor stated that when two separate regions of the spine are injured, either one can exacerbate the other by compensatory changes. In a VA treatment note, dated in January 2002, the Veteran was noted to have chronic neck and back radiculopathic pain syndrome since 1986 secondary to work-related injury while lifting a heavy object while in the military. In May 2002, the Veteran was noted to have radicular neck pain that was due to degenerative joint disease. In November 2002, a VA examiner noted the Veteran's reports of continued neck pain with headaches and radiating pain to the arms. The examiner also noted the results of magnetic resonance images obtained the previous June that showed a bulging disc at C3-4 and C4-5. The examiner diagnosed cervical disc disease and muscle strain. Although he commented that the Veteran's lumbar disc disease was related to the Veteran's military experiences, he did not provide an opinion regarding a possible relationship between the cervical spine disease and the Veteran's experiences in service or as secondary to the lumbar spine disease. In a March 2004 treatment note, the Veteran was reported to have chronic cervical pain related to degenerative joint disease of the cervical spine. In July 2004, a VA examiner noted a review of the claims file and the Veteran's reports that he had undergone cervical traction at military facilities. The examiner noted that he could not find military medical reports that showed cervical symptoms or traction. However, he noted that the Veteran had received VA outpatient medication, a soft collar or brace, and transcutaneous electric stimulation treatment for neck pain since 2002. After referring to the MRI images obtained in 2000, the examiner diagnosed cervical disc disease but did not provide an opinion on the etiology of the disorder, citing only the Veteran's statements of symptoms and treatment in 1986. In January 2007, the Veteran was afforded a VA Compensation & Pension (C&P) examination of the spine in conjunction with a claim for a higher evaluation for his service-connected lumbar spine disorder. The examiner did not examine or comment upon the Veteran's cervical spine disorder. In a July 2008 Board hearing, the Veteran again stated that he had experienced neck pain since his active duty for training in 1986. In October 2008, the Veteran was afforded a VA C&P examination of the spine. The Veteran reported that he injured his neck while on a two-week National Guard training in 1986. After a complete review and recitation of pertinent treatment records, and physical examination of the Veteran, the examiner diagnosed the Veteran with cervical disc disease and cervical degenerative joint disease. The examiner rendered the opinion that the Veteran's cervical spine disorder was less likely as not caused by the operation of the forklift in service in February 1986. The examiner provided the rationale that no cervical spine disorder was identified in 1986 and that the Veteran's discharge summary dated in March 1986 did not mention any neck condition. The examiner further opined that no opinion could be rendered associating the Veteran's cervical spine disorder with the Veteran's service-connected lumbar spine disorder because "such knowledge is not available in the medical literature." In addition, the examiner noted that no opinion could be rendered regarding whether the Veteran's cervical spine disorder is aggravated by the Veteran's lumbar spine disorder without speculation. In the joint motion, the parties determined that the October 2008 examiner did not provide sufficient rationale for his conclusions in the examination report, and found that the basis of his conclusion that any opinion would be speculation was not apparent based on a review of the record. Thus, the parties determined that the July 2010 Board decision should be vacated to allow VA to provide the Veteran with "an adequate medical examination in which the examiner provides sufficient rationale for his or her conclusions." See Joint Motion on page 3 (citing to Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008)). In December 2011, the Board remanded the claim for another VA examination, which was conducted in May 2012. The examiner reviewed the claims file, examined the Veteran, and diagnosed the Veteran with degeneration of cervical intervertebral disc and cervical spondylosis without myelopathy. The Veteran reported that he believed that his neck injury occurred with his back injury in 1986 while operating a heavy instrument during his 2-week active duty period. Upon review of all pertinent evidence of record, the examiner determined that the current claimed cervical spine condition is not caused by or a result of the Veteran's military service, to include the operations of a forklift in February 1986. The examiner further determined that the current claimed cervical spine condition is also not caused by or aggravated by or a result of service-connected lumbosacral condition. The examiner stated that, since there is no objective evidence of myelopathy, radiculopathy, or neuropathy, an opinion is not indicated. As rationale, the examiner noted that these opinions were based on a review of the available medical records, medical literature, and clinical experience. The examiner noted that service treatment records show the Veteran suffered a lower back injury during operations of a forklift in February 1986. Although the Veteran believes his neck injury happened with his back in 1986 while operating heavy instrument, the onset of the current cervical spine condition is unknown to the Veteran himself. As stated in VA-2507 and clearly documented during various lower back evaluations: neck examination was normal. An August 13, 1987, orthopaedic note evaluated the Veteran for "LBP & atypical limp" and clearly mentions that cervical spine x-rays were negative. Many years after discharge from military on October 29, 1996, the Veteran was diagnosed with degeneration of cervical intervertebral disc (bulging: C3-C4, C4-C5, C5-C6, & C7-T1 levels) and degeneration of thoracic intervertebral disc (bulging: T1-T2, T2-T3, and T3-T4 levels), during which period (as mentioned in the prior October 2008 VA examination and in medical records) the Veteran has had injuries and also a motor vehicle accident in 2006, which he denied during this examination, with unknown incidental injuries with his history of alcohol and substance abuse clearly documented in his medical treatment records with black-out spells. There is no objective evidence of claimed cervical spine and thoracic spine condition onset in military service or shortly after discharge from military service. There is no available medical literature to support a cause and effect relationship and aggravation if any between the claimed current neck and thoracic spine and the Veteran's service-connected lumbosacral strain with degenerative disc disease L4-5, L5-S1 with limited range of motion. Thus, nexuses cannot be made. In October 2012, the Board found that this claim must be remanded once again to request that the May 2012 VA examiner clarify his or her opinion regarding whether the Veteran's service-connected low back disability had caused or aggravated a cervical spine disability. In November 2012, the examiner provided another VA opinion. The examiner concluded that the current claimed cervical spine condition mentioned during the May 2012 VA examination is not caused by or aggravated by or a result of a service-connected lumbosacral condition. The examiner indicated that his or her rationale was based on a review of the available medical records, medical literature, and clinical experience. The examiner determined specifically that the Veteran's service-connected lumbosacral condition and current cervical spine condition are two separate conditions with no pathophysiological co-relation in this Veteran to support a cause and effect relationship and aggravation, if any. The examiner noted that there is no available medical literature to support a cause and effect relationship and aggravation, if any between the claimed current neck and thoracic spine condition and the Veteran's service-connected lumbosacral strain with degenerative disc disease L4-5; L5-S1 with limited range of motion. Thus, nexuses cannot be made. Upon review of the claims file, the Board finds that entitlement to service connection for cervical disc disease, to include as secondary to service-connected lumbar spine disorder, is not warranted. The Board recognizes Veteran's contentions that he has had a continuity of symptomatology of neck pain since his military service. However, the United States Court of Appeals for the Federal Circuit recently clarified that the continuity of symptomatology language in section 3.303(b) restricts itself to chronic diseases found in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), ("Nothing in § 3.303(b) suggests that the regulation would have any effect beyond affording an alternative route for proving service connection for chronic diseases."). While the Veteran has been diagnosed as having arthritis, his other diagnosed disabilities of cervical disc disease and spondylosis are not chronic diseases under section 3.309(a) and therefore, the Veteran may not establish continuity of symptomatology in lieu of a medical nexus for these disabilities. The Board observes that arthritis is recognized as a chronic disease under section 3.309(a). However, the Veteran's service treatment records do not note arthritis of the cervical spine during active military service. The Federal Circuit held in Walker that section 3.303(b) only applies to a chronic disease as listed under section 3.309(a) that was shown in service. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Thus, the Veteran may not establish continuity of symptomatology in lieu of medical nexus with respect to his arthritis of the spine. Additionally, the Board notes that the medical evidence of record does not reflect that the Veteran was diagnosed with arthritis of the cervical spine to a compensable degrees within one year of discharge from his period of active duty. As such, service connection cannot be granted for arthritis of cervical spine on a presumptive basis under 38 C.F.R. § 3.309(a). With regard to granting service connection on a direct basis based on the medical evidence of record, the Board notes that the Veteran has indicated that he has experienced neck pain since his active duty for training in February 1986. The Veteran's service treatment records reveal that the Veteran was treated for back pain in March 1986 and that the Veteran complained of neck discomfort. The Veteran's post service records reveal that the Veteran has been consistently diagnosed with a cervical spine disorder since October 1996. A February 2000 VA treatment record reflected a diagnosis of cervical degenerative joint disease, service-connected paperwork in progress. However, no rationale was provided by the clinician. In a treatment note, dated in January 2002, a VA physician reported that the Veteran had chronic neck radiculopathic pain since 1986 due to lifting a heavy object while in the military. However, after examination in May 2012, the opinion was rendered that the current claimed cervical spine condition is not caused by or a result of the Veteran's military service, to include the operations of a forklift in February 1986. The examiner noted that there is no objective evidence of a claimed cervical spine and thoracic spine condition onset in military service or shortly after discharge from military service. As the examiner rendered this opinion after a thorough review and recitation of pertinent evidence of record, and he or she provided a sufficient rationale for this opinion, the Board finds that the May 2012 VA opinion is the most probative opinion of record on the matter with regard to service connection on a direct basis. The Board has considered the opinion included in the January 2002 VA treatment record noting that the Veteran has had chronic neck and back radiculopathic pain syndrome since 1986 secondary to a work-related injury while lifting a heavy object while in the military. However, the Board finds this opinion less probative than the May 2012 VA opinion. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); Prejean v. West, 13 Vet. App. 444, 448-89 (2000). Specifically, there is no indication that this opinion is based on a complete review of the claims file, and this opinion does not include a rationale or any discussion as to the fact that the Veteran was not diagnosed with a neck disability for many years after service. Importantly, the clinician did not have the ability to review the service-treatment records, which did not show any abnormal findings with respect to the cervical spine. Therefore, the Board notes that March 1986 treatment records document a complaint of neck discomfort and a complaint of pain on the right side of the neck. However, as the most probative medical opinion of record on the matter specifically reflects that the current claimed cervical spine condition is not caused by or a result of the Veteran's military service, to include the operations of a forklift in February 1986, the Board finds that the preponderance of the evidence is against the claim for entitlement to service connection for a cervical spine disability on a direct basis. With regard to granting service connection on a secondary basis, the Board notes that a private chiropractor stated generally in a July 2001 letter that when two regions of the spine are injured either one can exacerbate the other by compensatory changes. The Board, however, finds that this opinion is speculative, as it only states that there can be an exacerbation, and that medical evidence that is speculative, general or inconclusive in nature cannot support a claim. The reasonable doubt doctrine requires that there be a "substantial" doubt and "one within the range of probability as distinguished from pure speculation or remote possibility." 38 C.F.R. § 3.102; see also Obert v. Brown, 5 Vet. App. 30, 33 (1993); Beausoleil v. Brown, 8 Vet. App. 459, 462 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996) (holding that any medical link that is speculative, general or inconclusive in nature is of no probative value and not a sufficient basis to grant service connection). To the contrary, after examination in May 2012, an opinion was rendered in November 2012 that the current claimed cervical spine condition mentioned during the May 2012 VA examination is not caused by or aggravated by or a result of service-connected lumbosacral condition. The examiner determined specifically that the Veteran's service-connected lumbosacral condition and current cervical spine condition are two separate conditions with no pathophysiological co-relation in this Veteran to support a cause and effect relationship and aggravation, if any. The examiner noted that there is no available medical literature to support a cause and effect relationship and aggravation, if any between the claimed current neck and thoracic spine condition and the Veteran's service-connected lumbosacral strain with degenerative disc disease L4-5; L5-S1 with limited range of motion. Thus, nexuses cannot be made. As the November 2012 VA examiner rendered this opinion after a thorough review and recitation of pertinent evidence of record, and he or she provided a sufficient rationale for this opinion, the Board finds that the November 2012 VA opinion is the most probative opinion of record on this matter with regard to service connection on a secondary basis. On the other hand, the Board finds the private chiropractor's statement to be not probative, as this statement was speculative and not supported by a rationale. Therefore, as the most probative medical opinion of record on the matter indicated that the current claimed cervical spine condition is not caused by or aggravated by or a result of service-connected lumbosacral condition, the Board finds that the preponderance of the evidence is against entitlement to service connection for a cervical spine disability on a secondary basis. The Veteran's credible and competent statements that he had neck symptoms since the injury on ACDUTRA have been considered, however, they are outweighed by the May 2012 and November 2012 VA medical opinions, which were based on an examination, a review of the medical history, and detailed rationale. While the Veteran is competent to report that he has had neck symptoms since his period of ACDUTRA, the Veteran, as a lay person, is not competent to provide a medical nexus opinion regarding the etiology of a currently diagnosed cervical spine disability, such as arthritis, spondylosis and degenerative disc disease, as such opinions require medical expertise. See Jandreau v. Nicholson, 492 F.3d at 1377 (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Therefore, with the preponderance of the evidence being against entitlement to service connection for a cervical spine disability, to include as secondary to a service-connected lumbar spine disorder, service connection is denied. In reaching the decisions above the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against entitlement to service connection, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for a cervical spine disability, to include degenerative disc disease and degenerative joint disease, to include as secondary to the service-connected lumbosacral strain with degenerative disc disease L4-L5, L5-S1 with radiculopathy is denied. ____________________________________________ S. S. Toth Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs