Citation Nr: 1318641 Decision Date: 06/07/13 Archive Date: 06/11/13 DOCKET NO. 07-22 017 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to an increased rating for degenerative changes and disc disease involving C5-6 and C6-7, status post operative anterior cervical discectomy with fusion C5-6, C6-7 with radiculopathy (cervical spine disability), currently rated as 20 percent disabling. 2. Entitlement to an initial evaluation in excess of 20 percent for right upper extremity radiculopathy as secondary to cervical spine disability. 3. Entitlement to an initial evaluation in excess of 20 percent for left upper extremity radiculopathy as secondary to cervical spine disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Chapman, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1969 to August 1978 and from August 1979 to May 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2006 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). During the pendency of the appeal, in a November 2012 rating decision, the RO awarded service connection for radiculopathy, right upper extremity and radiculopathy, left upper extremity, both as secondary to the service-connected cervical spine disability. The RO assigned a 20 percent rating for the right upper extremity, effective from September 7, 2012, and assigned a separate 20 percent rating for the left upper extremity, effective from November 9, 2011. As these issues are intertwined, they will both be addressed in this decision. Although a Board hearing was requested on the Veteran's VA Form 9, the Veteran subsequently withdrew his request in September 2011. This matter was previously remanded by the Board in October 2011 for additional development. FINDINGS OF FACT 1. Orthopedic manifestations of the Veteran's cervical spine disability are not manifested by forward flexion of the cervical spine 15 degrees or less, or favorable and unfavorable ankylosis of the entire cervical spine, or associated neurological disabilities for which the Veteran has not already been evaluated that would warrant a separate compensable evaluation; nor is there evidence of incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during any 12 month period during this appeal. 2. Prior to September 7, 2012, the Veteran's right upper extremity radiculopathy was manifested by no more than mild, incomplete paralysis. 3. From September 7, 2012, the Veteran's right upper extremity radiculopathy is manifested by no more than mild, incomplete paralysis. 4. Prior to November 9, 2011, there is no evidence to suggest the Veteran suffered from left upper extremity radiculopathy. 5. From November 9, 2012, the Veteran's left upper extremity radiculopathy is manifested by no more than mild, incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for cervical spine disability are not met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.27, 4.40, 4.45, 4.59, 4.71a, 4.123, 4.124, 4.124a, Diagnostic Codes (Codes) 5003, 5242, 5243 (2012). 2. Prior to September 7, 2012, the criteria for a rating of 20 percent for right upper extremity radiculopathy are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Codes 8510, 8511 (2012). 3. From September 7, 2012, the criteria for a rating in excess of 20 percent for right upper extremity radiculopathy are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Codes 8510, 8511 (2012). 4. From November 9, 2011 and no earlier, the criteria for a rating in excess of 20 percent for left upper extremity are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.124a, Codes 8510, 8511 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA), (codified at 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126), imposes obligations on VA in terms of its duty to notify and assist claimants. Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and 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). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that 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. VCAA notice must be provided prior to the initial unfavorable adjudication by the RO. Id. at 120. VCAA notice requirements apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; (3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Here, the Veteran is challenging the initial evaluation assigned following the grant of service connection for left upper extremity and right upper extremity radiculopathy. In Dingess, it was held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, VA's duty to notify as to the claim for an increased initial rating for that disorder has been satisfied. With respect to the increased rating claim for cervical spine disability, the VCAA requirement is generic notice, that is, notice of the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The appellant was advised of VA's duties to notify and assist in the development of this claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). December 2005, March 2006 and May 2008 letters explained the evidence necessary to substantiate the claim, the evidence VA was responsible for providing, and the evidence he was responsible for providing. The March 2006 and May 2008 letters also provided notice regarding ratings and effective dates of awards. The Veteran has therefore received the general-type notice described in Vazquez-Flores. The Veteran has had ample opportunity to respond/supplement the record, and has not alleged that notice in this case was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) ("where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream issues"). Concerning the VA's duty to assist, the Board notes that the Veteran's service treatment records (STRs), post-service VA and private treatment records, and his lay statements of argument have been obtained. Neither the Veteran nor his representative has identified any outstanding evidence, to include any other medical records, that could be obtained to substantiate the appeal. With respect to the examinations conducted in conjunction with this appeal, the Board observes that the findings contained therein are more than adequate to adjudicate the Veteran's claims. The Veteran was afforded VA examinations in January 2006, February 2009, October 2009 (with March 2010 addendum), November 2011, and September 2012. These examination reports reflect that each examiner reviewed the Veteran's past medical history, recorded the Veteran's current complaints, conducted appropriate examinations, and rendered appropriate diagnoses consistent with the other evidence of record. Accordingly, the Board finds that VA's duty to assist with respect to obtaining adequate VA examinations or opinions has been met. Barr v. Nicholson, 21 Vet. App. 303 (2007). The October 2011 remand requested that any additional VA treatment records be developed as well as Social Security Administration (SSA) records, and a new VA examination. The claims folder evidence reveals there are no additional VA treatment records that have not already been associated with the claims folders. SSA records were associated with the claims folder, and thorough VA examinations were developed in November 2011 and September 2012. Accordingly, the Board finds that there has been substantial compliance with the October 2011 remand. See Dyment v. West, 13 Vet. App. 141 (1999). The Board will address the issues on appeal. Legal Criteria Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). However, where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Nevertheless, a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. When VA grants a claim for an increased rating, it may assign an effective date up to one year before the date the claimant's application for increase was received, provided it is factually ascertainable that an increase in disability occurred within that timeframe. 38 U.S.C.A. § 5110(b)(2); Hart, 21 Vet. App. 505, 509 (2007). Here, the relevant evidentiary window for the cervical spine disability begins October 2004 (one year before the Veteran filed his claim for an increased rating), and continues to the present time. It should be noted that when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. A 20 percent rating for the Veteran's service-connected cervical spine has been in effect since 1992. As noted above, he filed the current claim for increase in October 2005. All cervical spine disabilities, with the exception of intervertebral disc syndrome, are rated using the same criteria, the General Rating Formula for Diseases and Injuries of the Spine. See 38 C.F.R. § 4.71a, Codes 5235-5242. Spine disabilities may be alternatively rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. See 38 C.F.R. § 4.71a, Code 5243. A compensable rating under this Formula requires the Veteran to have experienced incapacitating episodes, with bed rest as prescribed by a physician. See Note (1). The Veteran reported during his September 2012 VA examination that he had flare-ups, causing him to not be able to play golf or carry much weight on his right arm, and that his quality of life has decreased because of more pain. Considering this information, the 2012 VA examiner (in addition to the November 2011 VA examiner) found that while the Veteran had intervertebral disc syndrome, he has not had any incapacitating episodes, as defined by VA regulation, over the last 12 months. When specifically asked about incapacitating episodes during his October 2009 VA examination, the Veteran did not respond, but continued to maintain that the pain in his neck had gradually worsened over the past 4 months. There is no other evidence of record to suggest incapacitating episodes. In this case, the medical evidence does not reflect, nor does the Veteran contend, that he has ever been prescribed bed rest for his cervical spine disability (emphasis added). The preponderance of the evidence is therefore against a finding that the Veteran's service-connected cervical spine disability is manifested by incapacitating episodes as defined by VA regulation. Thus, the Veteran's service-connected cervical spine disability will be rated using the General Rating Formula for Diseases and Injuries of the Spine, and not the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The General Rating Formula for Diseases and Injuries of the Spine designates the following: A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 30 percent rating is warranted for forward flexion of the cervical spine of 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees, but not greater than 30 degrees; or for a combined range of motion of the cervical spine not greater than 170 degrees; or, for muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, Codes 5235-5242. Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. The Board notes that the RO has already awarded the Veteran a separate 20 percent disability rating for right upper extremity radiculopathy and a 20 percent rating for left upper extremity radiculopathy, based on recent medical evidence demonstrating evidence of radiculopathy due to the service-connected cervical spine disability. The Board will discuss the propriety of those initial ratings below. Note (2): For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. The normal combined range of motion of the cervical spine is 340 degrees. See 38 C.F.R. § 4.71a, Codes 5235-5242, Note (2) (2011). Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The Board notes that is has considered rating the Veteran's cervical spine disability under Code 5003 [arthritis], but has determined that doing so would not avail the Veteran. Code 5003 specifies that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate Code for the specific joint or joints involved. As noted above, all cervical spine disabilities, with the exception of intervertebral disc syndrome, are rated using the same criteria-the General Rating Formula for Diseases and Injuries of the Spine-which include consideration of any limitation of motion. See 38 C.F.R. § 4.71a, Codes 5235-5242. Analysis Initially, the Board notes that it has reviewed all the evidence in the Veteran's claims file and in Virtual VA (VA's electronic data storage system). Although the Board has an obligation to provide adequate reasons and bases supporting its decision, there is no requirement that the Board discuss every piece of evidence in the record. Rather, the Board will summarize the relevant evidence, as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Schedular Rating - cervical spine The Veteran has contended that his cervical spine disability is more severe than reflected by the 20 percent evaluation under Code 5242. As will be discussed further below, during the pendency of the appeal, a separate rating was awarded for his right upper extremity radiculopathy and left upper extremity radiculopathy related to his service-connected cervical spine disability. With respect to the orthopedic manifestations of the cervical spine, even when considering functional loss, the Veteran's forward flexion is not shown to be limited to 15 degrees or less and there is no evidence of ankylosis. January 2006 VA examination testing revealed forward flexion to 26 degrees after 4 repetitions and limited by pain; the examiner noted the absence of fatigue, weakness, or lack of endurance. The examiner noted no postural abnormalities or ankylosis. On February 2009 VA examination, forward flexion was to 25 degrees on repetitive motion. February 2009 x-rays showed moderate degenerative arthritic changes at C5-6 and C6-7. On October 2009 VA examination, range of motion studies revealed forward flexion to 45 degrees with no additional limitation on repetition or because of pain or fatigue. The March 2010 addendum to the February 2009 VA examination noted that ranges of motion of the neck were carried out for 3 repetitions with no further decrease in motion because of pain, fatigue, or lack of endurance. As such, the examiner concluded that the DeLuca parameters were addressed and his conclusions from the prior examination remained the same. On November 2011 VA examination, forward flexion was to 30 degrees, with objective evidence of painful motion beginning at 20 degrees and no additional limitation following repetitive use testing. On September 2012 VA examination, forward flexion was to 30 degrees with evidence of painful motion beginning at 20 degrees. After repetitive use testing, flexion was to 35 degrees. There was localized tenderness of the neck, but no guarding or muscle spasm. For the foregoing reasons, even when considering functional limitations due to pain and other factors identified in 38 C.F.R. §§ 4.40, 4.45, the Board finds that the Veteran's functional loss from the orthopedic manifestations of his cervical spine disability does not equate to more than the disability picture contemplated by the 20 percent rating assigned. 38 C.F.R. § 4.71a. This is so because the evidence does not show that his forward flexion is limited to 15 degrees or less, or that he has ankylosis of the cervical spine. Reviewing the evidence, the Board finds that the cervical spine disability picture does not at any time during the pendency of the appeal more closely approximate the criteria for a 30 percent or 40 percent rating under Code 5242. 38 C.F.R. § 4.7. The Board acknowledges the Veteran's statements attesting to increased pain warranting a higher rating, in addition to private and VA treatment records noting continued treatment for his cervical spine. Specifically, the Board notes a January 2012 opinion from a private physician noting the Veteran's continued progressive cervical spine pain and loss of motion with right arm radicular symptoms, which he believes the VA should consider. However, the preponderance of the evidence, specifically the very thorough and numerous VA examinations performed over the course of this appeal, are against a finding that the Veteran had limitation of flexion to 15 degrees or less, even with consideration of pain on motion. For example, the 2011 and 2012 VA examination reports specifically addressed pain with respect to limitation of motion and found that the Veteran had 20 degrees of pain-free motion. Thus, this evidence does not supply a basis for providing an increased rating under Diagnostic Code 5242. Schedular Rating - right upper extremity radiculopathy & left upper extremity radiculopathy As indicated above, Note (1) of the General Rating Formula directs that any objective neurologic abnormalities associated with a Veteran's service-connected cervical spine disability should be evaluated separately under an appropriate diagnostic code. The RO has awarded the Veteran a separate 20 percent evaluation for right upper extremity radiculopathy from September 7, 2012, the date of the VA examination findings, and a separate 20 percent evaluation for left upper extremity radiculopathy from November 9, 2011, the date of the VA examination findings. The Board notes that the Veteran appears to have been rated only under Code 8511 for paralysis of the middle radicular group; however, given that the September 2012 VA examiner identified both the upper radicular group and middle radicular group as the group of nerves affected, the Board finds it appropriate to consider both Code 8510 (the diagnostic code for paralysis of the upper radicular group) and Code 8511(the diagnostic code for paralysis of the middle radicular group); however, the Board notes that there is no prejudice to the Veteran if rated under either Code because the ratings are the same. For impairments related to the major or minor extremity in the upper radicular group or the middle radicular group, a 20 percent rating is warranted for "mild" incomplete paralysis. Where "moderate" incomplete paralysis is demonstrated, a 40 percent rating is warranted for the major extremity, and a 30 percent rating is warranted for the minor extremity. For "severe" incomplete paralysis, a 50 percent rating is warranted for the major extremity, and a 40 percent rating is warranted for the minor extremity. Finally, where paralysis is complete, as all shoulder and elbow movements are lost or severely affected while hand and wrist movement are not affected (upper radicular group) or adduction, abduction, and rotation of arm, flexion of elbow, and extension of wrist are lost or severely affected (middle radicular group), a 70 percent rating is warranted for the major extremity, and a 60 percent rating is warranted for the minor extremity. 38 C.F.R. § 4.124a , Codes 8510, 8511. The Board notes that words such as "slight," "moderate," and "severe" are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6. On January 2006 VA examination, a neurologic examination showed the cranial nerves to be intact; cerebellar function studies were normal; deep tendon reflexes were 1/3 and symmetric; and no pathologic reflexes were elicited. The examiner did find that sensory modalities revealed some decreased vibratory over the knuckle of the right index finger, otherwise within normal limits. The diagnosis was postoperative status cervical compression syndrome C5-C6 with radiation into the radial distribution of the right arm. On February 2009 VA examination, the Veteran reported an occasional daily increase in numbness (or a funny feeling) in the right hand. He also stated that if he twists to the right side, he would have a sudden increase in the neck pain. The examiner noted that he visualized no atrophy about the upper extremities and found no increased pain with cervical compression and passive rotation. On October 2009 VA examination report, the examiner noted decreased sensation to light touch on the thumb side of the hand. There was no loss of motion in the fingers, wrists, forearms, elbows, or shoulders. Grip strength was normal. Biceps and triceps deep tendon reflexes as well as brachial radialis also appeared to be normal. To verify objectively the subjective complaints of changes in the right upper extremity when he rotates to the right side, the examiner order an EMG nerve conduction study. October 2009 VA needle electromyography found no EMG evidence of acute right cervical radiculopathy at levels C5-8 and T1. A November 2009 private needle electromyography found similarly. However, a December 2009 record noted a diagnosis of cervical radiculopathy. In September 2011, the Veteran was seen for neck pain and numbness in the right fourth and fifth fingers. On November 2011 VA examination, the Veteran was diagnosed with cervical radiculopathy, consisting of mild paresthesias and/or dysesthesias in the left upper extremity and mild numbness in the left upper extremity. The examiner rated the severity of this radiculopathy as mild. On September 2012 VA examination, a diagnosis of cervical degenerative disc disease with left arm radiculopathy was noted. Elbow flexion and extension, wrist flexion and extension, and finger flexion and abduction were rated as normal. No muscle atrophy was noted. Reflexes were also normal for the biceps, triceps, and brachioradialis. A sensory examination found decreased sensation on the right inner/outer forearm and decreased sensation in the right hand/fingers. The examiner noted that the Veteran had radiculopathy consisting of mild numbness in the right upper extremity; no numbness was noted for the left upper extremity. There was involvement of the C5/C6 nerve roots (upper radicular group) and the C7 nerve roots (middle radicular group). Based on a review of all of the lay and medical evidence of record, the Board finds that throughout the entire pendency of the appeal (and not just from September 2012 VA examination), the Veteran's right upper extremity radiculopathy is shown to be no more than "mild" in severity. On January 2006 VA examination, the examiner noted radiation into the radial distribution of the right arm. On February 2009 VA examination, the Veteran reported numbness in his right hand and a neck pain when twisting to the right. Although a VA and private EMG in 2009 found no evidence of acute right cervical radiculopathy, a December 2009 treatment record did note a diagnosis of cervical radiculopathy. Thus, considering this evidence and affording the Veteran the benefit of the doubt, the Board finds that the Veteran suffered from no more than "mild" radiculopathy throughout the entire pendency of the claim. On September 2012 VA examination, the examiner described the radiculopathy of the right upper extremity as "mild" and there is no other evidence to suggest the Veteran has suffered any more than mild, incomplete paralysis. The evidence shows that muscle strength was normal and no atrophy was noted. Accordingly, a preponderance of the evidence is against a finding that the Veteran suffered from more than mild, incomplete paralysis (a 20 percent rating) at any time during the pendency of the claim. As for left upper radiculopathy, there is no evidence in the record prior to the November 2011 VA examination to suggest the Veteran suffered from left upper radiculopathy prior to this date. On November 2011 VA examination, the examiner diagnosed the Veteran with cervical radiculopathy, consisting of mild paresthesias and/or dysesthesias in the left upper extremity and mild numbness in the left upper extremity. The examiner rated the severity of this radiculopathy as mild. Further, on September 2012 VA examination, the examiner noted left arm radiculopathy, but provided no evidence to suggest anything more than mild impairment. Thus, a preponderance of the evidence supports findings that the Veteran did not suffer from left arm radiculopathy prior to November 9, 2011, and suffered from no more than mild, incomplete paralysis of the left upper extremity from November 9, 2011. Accordingly, a preponderance of the evidence is against a finding that the Veteran suffered from more than mild, incomplete paralysis at any time during the appeal. Extraschedular Considerations First, the Board notes that it has (1) considered Mittleider, and (2) attributed all potentially service-connected symptoms to one service-connected condition or another, before (3) considering if the Veteran is entitled to an extraschedular rating. See Mittleider v. West, 11 Vet. App. 181 (1998). The Veteran's impairment is adequately contemplated by the rating criteria. The Board has also considered whether the Veteran's cervical spine disability with radiculopathy presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2010); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). In this case, there are no exceptional or unusual factors with regard to the Veteran's disability on appeal. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe his disability level and symptomatology. The criteria for the Diagnostic Codes applied herein include consideration of limitation of motion, numbness, loss of sensation, and pain, the symptoms reported by the Veteran. Further, the applicable diagnostic codes provide for more severe symptoms than shown by the evidence during the period in question; thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Hence, referral for extraschedular consideration is not warranted. The evidence of record indicates the Veteran has difficulty with neck range of motion and using his right hand, for which he is receiving compensation, but it is not alleged (or suggested by the record) that the Veteran's service-connected disabilities, including his cervical spine disability, prevent him from engaging in gainful employment. The evidence reveals the Veteran has not worked since 2009 because he was laid off due to the economy. Further, Social Security Administration (SSA) records show that since October 2009, the Veteran is disabled primarily due to ischemic heart disease. By the Veteran's own report he stopped working as a result of disability caused by a nonservice-connected blood clot that caused lung damage. See written statement from Veteran dated September 2011. Hence, the matter of entitlement to [an extraschedular] TDIU rating is not raised in the context of the instant claim for increase. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER Entitlement to a rating in excess of 20 percent for cervical spine disability is denied. Prior to September 7, 2012, entitlement to a rating of 20 percent for right upper extremity radiculopathy, but no higher, is granted, subject to the laws and regulations governing the payment of monetary benefits. From September 7, 2012, entitlement to a rating in excess of 20 percent for right upper extremity radiculopathy is denied. Prior to November 9, 2011, entitlement to a separate rating for left upper extremity radiculopathy is denied. From November 9, 2011, entitlement to a rating in excess of 20 percent for left upper extremity radiculopathy is denied. ____________________________________________ M.C. GRAHAM Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs