Citation Nr: 1326181 Decision Date: 08/16/13 Archive Date: 08/26/13 DOCKET NO. 05-10 647 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to separate compensable ratings for neurological manifestations of a low back disability other than left lower extremity radiculopathy. 2. Entitlement to a rating in excess of 10 percent for left leg radiculopathy. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K.S. Hughes, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from November 1969 to April 1975. These matters are before the Board of Veterans' Appeals (Board) on appeal from a January 2004 rating decision by the Indianapolis RO that continued a 40 percent rating for the Veteran's low back disability. In February 2005, the RO assigned a separate 10 percent rating for radiculopathy of the left lower extremity, from August 14, 2003, the date of claim for an increased rating, thereby increasing the combined rating for orthopedic and neurological symptoms of the low back disability to 50 percent. In March 2006, a Travel Board hearing was held before the undersigned. In October 2006 and July 2009, the Board remanded the matter of the combined rating for a low back disability for additional development. In June 2012 (when the Board also denied a rating in excess of 40 percent for orthopedic manifestations of the low back disability) and in March 2013, the Board remanded the appeal as to neurological manifestations for additional development. A July 2005 (during the pendency of this appeal) unappealed (and now final; See 38 U.S.C.A. § 7105) rating decision denied the Veteran a total disability rating based on individual unemployability (TDIU). The June 2012 Board decision noted that May 2012 written argument by the Veteran's representative appears to be re-raising the matter, and referred the matter to the RO for any appropriate action. As there appears to have been no action pursuant to the referral, the matter is once again referred to the RO for appropriate action. FINDINGS OF FACT 1. The Veteran/s service connected low back disability is not shown to have any neurological manifestations other than left leg radiculopathy. 2. At no time during the period for consideration are symptoms of the Veteran's left leg radiculopathy shown to have resulted in more than mild incomplete paralysis of the external popliteal nerve. CONCLUSIONS OF LAW 1. Separate compensable ratings for neurological manifestations of a low back disability other than left lower extremity radiculopathy are not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.310, 4.71a, Diagnostic Code (Code) 5243 (2012). 2. A rating in excess of 10 percent for left leg radiculopathy is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Code 8521 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). It applies to the claim on appeal. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The instant appeal arose from an August 2003 claim for an increased rating for the Veteran's service-connected low back disability (he was awarded a separate 10 percent rating for radiculopathy of the left lower extremity and seeks separate compensable ratings for additional neurological manifestations (bladder/urinary dysfunction, erectile dysfunction, and right lower extremity radiculopathy) and a rating in excess of 10 percent for left leg radiculopathy). In a claim for increase, the VCAA requirement is generic notice, that is, 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) (Fed. Cir. 2009). The Veteran was advised of VA's duties to notify and assist in the development of the claim prior to its initial adjudication. A September 2003 letter explained the evidence necessary to substantiate his claim for an increased rating, the evidence VA was responsible for providing, and the evidence he was responsible for providing. Letters in April 2005, January 2006, November 2006 and July 2009 provided additional information regarding rating criteria (the November 2006 letter also provided notice as to the requirements for service connection and the July 2009 letter provided notice as to the requirements for the assignment of separate ratings for neurologic abnormalities). Notably, at the March 2006 Travel Board hearing the Veteran was advised of what was needed to substantiate his claim for an increased rating based on neurologic impairment. He expressed awareness of what is needed (indicating that he would seek such evidence from his treating physician). Subsequent supplemental statements of the case, most recently in May 2013, readjudicated the matter (curing any notice timing defect). See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). He has received Vazquez-Flores compliant notice, and has had ample opportunity to respond/supplement the record (the July 2009 letter provided Vazquez-Flores specific notice.) It is not alleged that notice was less than adequate. The Veteran's service treatment records (STRs) and pertinent postservice treatment records have been secured. The RO arranged for VA examinations in October 2003, February 2005, June 2005, March 2007, March 2008 (with addendum unrelated to the present claims in April 2008), February 2010 (with addendum in March 2010) and April 2013 (specifically to determine the severity of the left leg radiculopathy and the nature and etiology of any other neurological manifestations of the low back disability). The Board finds that the examinations (and addenda) cumulatively are adequate for rating purposes, as the examiners were familiar with the history of the diasability and conducted thorough examinations, noting all findings necessary for consideration of the claims. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). The RO's actions have substantially complied with the October 2006, July 2009, June 2012 and March 2013 remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is a met. Factual Background Initially, the Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, 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 claims. The Veteran's STRs show an August 1974 complaint of nausea, vomiting, low back pain and increased urinary frequency and note that he was in an automobile accident in May 1974. A March 1975 Medical Board report shows a primary diagnosis of mild chronic left herniated nucleus pulposus at L4-5. The records are silent as to urinary or erectile dysfunction. A September 1975 rating decision granted the Veteran service connection for left herniated nucleus pulposus, which has been rated 40 percent since March 1993. The February 2005 rating decision assigned a separate 10 percent rating for the left lower extremity radiculopathy, effective August 14, 2003, the date of the claim for an increased rating. An October 2003 VA spine examination report notes the Veteran's complaints of daily back pain which periodically radiates down his legs. He was able to heel and toe walk. The examiner noted no clear radiculopathy on examination. Private treatment records include a June 2004 treatment report which notes complaints of low back pain which "radiates down back of both legs" and occasional numbness on the bottom of both feet. On February 2005 VA spine examination, the Veteran described fairly constant pain with varying degrees of radicular symptoms over the years. On examination, straight leg raises were negative bilaterally and sensation was intact throughout both lower extremities. Deep tendon reflexes were symmetric at the patella tendon, medial hamstring, and Achilles tendon. Motor examination revealed 5/5 strength throughout the right lower extremity and 4+/5 in the left quadriceps and hamstrings with pain inhibition. The Veteran's gait was mildly antalgic. On February 2005 VA peripheral nerves examination, the Veteran complained of left leg aches and burning down into the bottom of his foot which had become progressively worse over the past year. He described it as an achy feeling with an occasional burning sensation in the left lateral aspect of his leg, from his buttock all the way down to the sole of his foot. He also complained of intermittent/occasional burning achy pain in the medial aspect of the lower right leg beneath the knee. He had not had any bowel or bladder difficulty. On examination, the Veteran had a normal gait, and normal bulk, tone and strength throughout. The straight leg test was negative, muscle stretch reflexes were symmetric and within normal limits throughout, and light touch, pinprick, vibratory sense and position sense in all four distal extremities were intact. The examiner noted a small circular patch of numbness, which was decreased to pinprick and light touch, on the lateral aspect of the left knee in the distribution of the infrapatellar nerve. The examiner recommended an EMG (electromyograph) and nerve conduction study to rule out radiculopathy versus a peripheral neuropathy. A March 2005 EMG/nerve conduction report of the lower left extremity showed focal peroneal motor neuropathy at the ankle and chronic lumbar radiculopathy, which could not be localized. In his March 2005 substantive appeal, the Veteran reported problems going to the bathroom and feeling that he needed to urinate but could not. He complained of occasional pain and leakage. On June 2005 VA general medical examination (in connection with a TDIU claim), the Veteran complained of sciatica in both legs, left greater than right, and occasional burning and numbing sensations in his feet (he had no hypoesthesias in his feet however). He also reported that he "dribbles occasionally from his penis." On examination, the Veteran had "decreased sensation over his lateral knee." The diagnosis was chronic sciatica. At the March 2006 Travel Board hearing, the Veteran reported weakness and balance problems in both legs and burning in both feet. A March 2006 EMG/nerve conduction velocity study was "abnormal with evidence of subacute and chronic denervation changes best fitting the L4 nerve root distribution bilaterally." The findings were "consistent with an active radiculopathy." There was also "evidence of mild slowing in the left peroneal nerve, which could contribute to paresthesiae about the knee on the left side." A November 2006 statement from R. W. Mouser, M.D., notes that the Veteran experiences pain "down both legs; his soles feel hot and have gotten worse each month, ankles painful to walk which mean he has to sit down." In a January 2007 statement, the Veteran reported a history of erectile dysfunction as a result of pain. On March 2007 VA neurological examination, the Veteran reported increased weakness, especially in the ankles, feeling a bit more unsteady on his feet, and an increased burning type of pain (usually in the hips but occasionally radiating to the knees). He did not have any bowel or bladder problems but reported urinating more frequently over the last two to three years. Lower extremity examination showed some hamstring weakness (4/5 in the right and 4+/5 in the left); however, other muscle groups (iliopsoas, quadriceps, gastrocs, anterior tibialis and exterior hallucis longus) were 5/5 bilaterally. Sensation was diminished to pinprick over the lateral thigh and knee and lateral lower leg on the left and was intact on the right. The Veteran also had "some patchy and inconsistent sensory exam in the foot both dorsally and plantar." Heel to shin testing showed some slow movement, but otherwise no dystaxia. Reflexes were 2+ throughout, and the Veteran had a slow, slightly wide-based gait. He was able to walk on his tiptoes and heels, but he walked tandem gait in a cautious, somewhat disequilibrium patter. Other than some tightness in the hamstrings, straight leg test was negative. The impression was back pain with radicular symptoms. The Veteran's "deficits" were "referrable to the lower lumbar spine, perhaps the L3 nerve root on the left and the S1 nerve root innervating the hamstring bilaterally, more on the right." On March 2008 VA spine examination, the Veteran complained of low back pain and numbness extending down into the left buttock and radiating to the posterior aspect of the knees, slightly above the ankle, and occasional numbness over the sole of the foot, greater on the lateral than the medial side. On physical examination, the Veteran had a normal gait, a lot of balance problems walking on his heels and toes, "quads and hams 5/5," and deep tendon reflexes were 2+ at the knees and ankles. The diagnosis was chronic low back pain secondary to possible herniated disc disease, facet lumbar arthritis, and persistent right radiculopathy. [Notaby, although the diagnosis was "right radiculopathy," the examination report shows numerous notations of the Veteran's complaint of radiation into the left lower extremity. It is not inappropriate to correct errors with regard to inadvertent misdesignations of "right" or "left" as required. See Gifford v. Brown, 6 Vet. App. 269 (1994).] On February 2010 VA spine examination, the Veteran complained of continued back pain radiating to the left buttocks and back of legs. He also reported a history of urinary frequency and urgency, erectile dysfunction, numbness, paresthesias, leg or foot weakness, falls and unsteadiness. He did not have urinary incontinence. Detailed lower extremity motor examination was 4/5 on the left and 5/5 on the right and sensory and reflex examinations were normal for both lower extremities. The examiner opined that the etiology of the Veteran's urinary frequency/urgency and erectile dysfuntion is not unrelated to his back disability (notably, phrased in a double negative, suggesting that they are related). On February 2010 peripheral nerves examination, the Veteran complained of bilateral leg weakness, numbness (sides of thighs), paresthesias, dysesthesias, pain (burning pain in upper legs and burning sensation at soles of feet), and incoordination. Motor, sensory and reflex examinations were as reported on spine examination and the affected nerves were the peroneal/sural. An EMG study of both legs was normal; there was no evidence of neuropathy or left lumbosacral radiculopathy. The diagnosis was bilateral lower extremity radiculopathy with paralysis. A March 2010 addendum opinion notes that the Veteran has "persistent low back pain and left radiculopathy predominantly. Mild symptoms have been on the right side on occasion." The examiner stated that the "[f]inal diagnosis should indicate left lateral radiculopathy." [A review of the addendum opinion suggests that the examiner reviewed the March 2008 VA spine examination (which he performed) rather than the February 2010 VA spine and peripheral nerves examinations (which were by a different physician.)] As the record showed that the Veteran had complaints of urinary/bladder frequency, erectile dysfuntion and pain radiating into the right leg and there was conflicting medical evidence regarding such complaints, June 2012 and March 2013 Board remands sought clarification as to whether he has neurological manifestations of his low back disability other than left lower extremity radiculopathy (in particular of the right lower extremity, bladder/urinary function, and erectile dysfunction). On April 2013 VA back examination (by a neurologist), after examination of the Veteran and review of his claims file, the diagnosis was degenerative disc disease of the lumbar spine with herniated necleus pulposus of left L4-5. The examiner noted: The vetersn is now claiming service connection for bladder/urinary function as secondary to his service connected back condition. The veteran states that he began to have symptoms about one year ago that he describes as increased frequency of urination, dribbling after he completes urination, and difficulty starting and stoppng his stream. The veteran has never sought medical care, made complaints of, been worked up for, been diagnosed with, or been treated for any urinary system complaints including these at any time. (My note: this will be further discussed in the Remarks section, but this is not consistent with signs and symptoms of spinal cord problems due to a back condition and is consistent with age-related benign prostatic hypertrophy.) The veteran states that he developed symptoms of erectile dysfunction about 5 years and that he was initially treated with Viagra. No record of any prescription of this type was located in the evidence of record. It is also noted that no record of medical care, complaints of, work up for, diagnosis of, or treatment of erectile dysfunction is found in the evidence of record other than a previous compensation and pension examination in February 2010. Thus, this appears to be a disability diagnosis but not a treatment diagnosis. The veteran attributes erectile dysfunction to his back condition. (My note: this will be further discussed in the Remarks section, but this is not consistent with signs and symptoms of spinal cord problems due to a back condition and is consistent with age-related erectile dysfuntion.) On examination, muscle strength was 5/5, reflex and sensory examinations were normal, and the straight leg raising test was negative for both lower extremities. The examiner noted that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy, and there were no other neurologic abnormalities or findings related to a back condition (such as bowel or bladder problems/pathologic reflexes). Further, the examiner noted that the "veteran is noted to actively resist all attempted physical maneuvers, but there are no objective signs and symptoms correlated with his declarations of pain. The veteran appears to be attempting to exaggerate his examination findings for purposes of disability compensation." The examiner reviewed a September 2012 magnetic resonance imaging (MRI) of the lumbar spine and noted the vertebral alignment was normal; no marrow replacing process was evident in the conus, and found "the MRI argues against any bowel/bladder/erectile dysfunction conditions." Regarding the February 2010 EMG, the examiner commented: EMG of the bilateral lower extremities done 2/17/10 shows a normal study with no evidence of neuropathy or left lumbosacral radiculopathy. The ordering physician added an addendum that is a bit nonsensical in that it is difficult to interpret what he was attempting to communicate. It appears that he disagrees with the findings of this objective test but give no technical rationale as to why the EMG was incorrectly interpreted. To my reading as a board certified neurologist trained and experienced in performing and interpreting EMGs, it appears that this ordering examiner was simply unhappy with the result and wanted it to be different. Upon examination of the Veteran and review of the claims file, the examiner opined that the Veteran's "left lower extremity radiculopathy previously diagnosed has since resolved" and explained: The veteran previously was diagnosed with radiculopathy of the left lower extremity. However, it should be noted that radiculopathy is not a static condition. The general course of radiculopathy, which is any impingement or inflammation of a nerve root in the area of the neural foramen, is that as the impingement and/or inflammation subside, so does the effect of the nerve root. Thus, one can have fairly severe signs and symptoms of radiculopathy at one point in time and then later have the condition imporove to the point that it can and frequently does resolve without residuals. That appears to be the case with this veteran given that he had an EMG done in 2005 which clearly showed radiculopathy. His repeat EMG done in 2010 showed that the condition had resolved. There is no objective evidence at this time for radiculopathy in either lower extremity given that the veteran has both a normal neurological examination at this time and that his most recent EMG, which is more sensitive than clinical examination, is also normal. There are no symptoms or objective impairment of function of any left lower extremity radiculopathy at this time. The veteran does not have incomplete nerve paralysis that is mild, moderate, or severe or a disability consistent with complete paralysis of a nerve. His former condition of mild left lower extremity radiculopathy has since resolved without residuals. Regarding other neurological abnormalities, the examiner opined that the Veteran "has no neurological manifestations of lumbosacral disc disease including radiculopathy of the left lower extremity and specifically involving the right lower extremity, bladder/urinary function, or erectile dysfunction. There are no additional neurological manifestations found." The examiner opined further that it is less likely than not (less than 50/50 probability) that the Veteran's benign prostatic hypertrophy (claimed as bladder/urinary function) and/or erectile dysfunction are caused by, or related to, his service connected back condition, explaining: With respect to the veteran's claimed conditions of bladder/urinary function and erectile dysfunction: please note that it takes either spinal cord injury to the point that either the sympathetic nervous system tracks and/or the parasympathetic nervous system tracks are interrupted or that there is a pathological process located at the cauda equina, which is the level where the spinal cord ends and the horse's tail (cauda equina) of the nerve roots running through the lumbosacral area begins. The former is consistent with overt spinal cord injury in some way, and the veteran clearly does not have any of the conditions associated with this. The latter is associated with a condition known as cauda equina syndrome. The veteran's known disc herniation(s) are not in the area of the cauda equina, and his examination findings are not consistent with those of cauda equina syndrome since he has a normal neurological examination. It should also be noted that cauda equina syndrome develops - not years and certainly not multiple decades after back injury - but rather immediately upon injury. It then improves with time. It is noted that the veteran has complaints that bear no relationship to the bowel/bladder/erectile dysfunction symptoms of true cauda equina syndrome. His symptoms are completely consistent with age-related benign prostatic hypertrophy, which is a condition common to men of his age, and of erectile dyfunction consistent with both his age and the medications used to treat other medical conditions. It is also noted in passing that neither of these conditions appears to be chronic or disabling since the veteran has not sought treatment for either. Therefore, there is no pathophysiological reason to attribute the veteran's complaints to his service connected back condition and a strong pathophysiological reason to diagnose him appropriately with these common conditions. The examination report shows that the examination was by a physician "board certified in neurology, board eligible in pain management, and thus highly trained in the pathology of the spine." Legal Criteria and Analysis When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Service Connection The Veteran claims that, in addition to left lower extremity radiculopathy, he has other neurological symptoms of the service-connected low back disability, bladder/urinary dysfunction, erectile dysfunction and radiating pain into the right leg. Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Briefly, the legal requirements for a successful secondary service connection claim are: (1) evidence of a current disability for which secondary service connection is sought; (2) a disability which is service connected; and (3) competent evidence of a nexus between the two. Regarding separate evaluations for associated chronic neurologic manifestations, it is noted that during the appeal period since the Veteran's August 2003 claim for an increased rating, his service-connected low back disability (herniated nucleus pulposis, L4-5) has been evaluated as intervertebral disc syndrome (IVDS) under Code 5293 (as in effect prior to September 26, 2003) and under Code 5243 (effective September 26, 2003). Under the criteria in effect from September 23, 2002 until September 26, 2003, IVDS is evaluated (preoperatively or postoperatively) either on the total duration of incapacitating episodes over the past 12 months, or by combining under 38 C.F.R. § 4.25 (combined rating tables) separate evaluations of its chronic orthopedic and neurological manifestations along with evaluations for all other disabilities, whichever method results in the higher evaluation. "'Chronic orthopedic and neurological manifestations' means orthopedic and neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly or nearly so. See 38 C.F.R. § 4.71a, Diagnostic Code 5293, Note (1) (2003). Under the criteria effective September 26, 2003, IVDS is rated under the General Rating Formula for Rating Diseases and Injuries of the Spine (General Rating Formula). 38 C.F.R. § 4.71a, DCs 5237-5242. Note (1) following the General Rating Formula provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Neurological Impairment Consisting of Urinary and Erectile Dysfunction Due to IVDS It is not in dispute that the Veteran has some urinary/bladder dysfunction (benign prostatic hypertrophy) and erectile dysfunction. He claims that such impairment is a manifestation of his service-connected low back disability (and warrants a separate compensable rating). To substantiate such claim he must show that his urinary and erectile dysfunction are indeed manifestations of his service-connected low back disability. The record includes both medical evidence that potentially supports the Veteran's claim, and medical evidence that is against the claim. When evaluating this evidence, the Board must analyze its credibility and probative value, account for evidence which it finds to be persuasive or unpersuasive, and provide reasons for rejecting any evidence favorable to the appellant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The evidence that tends to supports the Veteran's claims that his urinary and erectile dysfunction are manifestations of his service-connected low back disability consists of the February 2010 VA spine examination when the examiner opined that the "etiology of the Veteran's urinary frequency/urgency and erectile dysfuntion is not unrelated to his back disability." However, this opinion is expressed as a double negative (leaving its meaning ambiguous), the examiner provided no explanation of rationale for the opinion offered, and urinary function and erectile dysfunction are not included in the diagnosis portion of the examination report. Therefore, the opinion of the February 2010 VA examiner is lacking in probative weight. The evidence weighing against the Veteran's claim consists of the April 2013 VA examination report wherein a Board certified neurologist (Board- eligible in pain management) who reviewed the entire claims file, including the various medical opinions and treatment reports already of record, and opined that the Veteran's urinary and erectile dysfunction are "not consistent with signs and symptoms of spinal cord problems due to a back condition." The examiner noted that the Veteran's urinary/bladder function is "consistent with age-related benign prostatic hypertrophy" and his erectile dysfunction is consistent with "both his age and the medications used to treat other medical conditions." In evaluating medical opinions, the Board may place greater weight on one medical professional's opinion over another's depending on factors such as reasoning employed by the medical professionals, and whether or not and to what extent they review prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). The Board accords great probative value to (and finds persuasive) the April 2013 VA examiner's opinion. As was noted, it was by a physician who by virtue of training and experience is eminently qualified to offer the opinion; includes a complete description of the low back and lower extremity orthopedic and neurologic symptoms claimed by the Veteran; reflects familiarity with the clinical data and the Veteran's complete medical history; shows consideration of the Veteran's statements and the evidence supporting his claims; identifies nonservice-related etiological factors (age) for the Veteran's urinary function and erectile dysfunction complaints considered more likely; and includes a complete explanation of rationale (with citation to factual data). Accordingly, the Board finds that the preponderance of the evidence is against a finding that any urinary or erectile dysfunctions are neurological manifestations of the service-connected low back disability and concludes that separate compensable ratings for such manifestations are not warranted. See 38 C.F.R. §§ 4.3, 4.71a. Neurological Impairment Consisting of Right Lower Extremity Radiculopathy Due to IVDS The threshold requirement for establishing entitlement to a separate compensable rating for a neurological disability as a manifestation of IVDS is that there must be competent evidence of such disability. Here, there is no objective evidence that the Veteran has a right lower extremity radiculopathy. The Board acknowledges the Veteran's complaints of burning pain, weakness and numbness radiating into his right leg. However, the United States Court of Appeals for Veterans Claims (Court) has held that pain alone, without a diagnosed or identifiable underlying malady or condition, is not in and of itself a compensable disability. Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). The Veteran's private physician, Dr. Mouser, has provided statements noting the Veteran's complaints of pain radiating into the right leg. However, these statements are not supported by clinical findings of related pathology. Further, although the February 2010 VA examination report includes a diagnosis of bilateral lower extremity radiculopathy with paralysis; however, this diagnosis is inconsistent with the clinical findings which show that the right lower extremity was normal on motor, sensory and reflex examination and EMG study. Similarly, while the March 2010 VA addendum opinion notes mild symptoms on the right side, the provider did not offer a diagnosis of a right lower extremity disability. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support [the] opinion"). Therefore, these medical statements/opinions have limited probative value. In contrast, the April 2013 VA examiner's opinion reflects review of/familiarity with the entire record, acknowledges (and explains rationale for disagreeing with) the statements and opinions tending to support the Veteran's claim, and explains the rationale for all opinions, citing to supporting clinical data. The April 2013 examiner opined that the Veteran "has no neurological manifestations of lumbosacral disc disease ... specifically involving the right lower extremity." He explained that the Veteran had normal right lower extremity neurological examinations. The April 2013 VA examiner is a Board-certified neurologist (qualified to offer an opinion in this matter). Because the opinion reflects familiarity with the Veteran's entire medical history and complete factual data and includes rationale that cites to supporting clinical data, the Board finds that it has substantially greater probative value than the statements by Dr. Mouser, the February 2010 VA examination report, and the March 2010 VA addendum opinion, considered separately, and combined. Gabrielson v. Brown, 7 Vet. App. 36 (1994). In summary, it is not shown that the Veteran has neurological manifestations of his service-connected low back disability consisting of right lower radiculopathy. Accordingly, a separate compensable rating for such manifestation is not warranted. Because the Veteran is a layperson, his own opinion as to whether any lower extremity complaint is a compensable neurological manifestation of his IVDS is not competent evidence. While he is certainly competent to observe he has such a complaint or symptom whether it constitutes a separate disability entity and is a neurological manifestation of a low back disability are complex medical questions beyond a layperson's observation capability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (Whether lay evidence is competent and sufficient in a particular case is a fact issue to be addressed by the Board rather than a legal issue to be addressed by the Court). Accordingly, the preponderance of the evidence is against the Veteran's claim for separate compensable ratings for neurological symptoms of his service-connected low back disability other than left lower extremity radiculopathy (to specifically include bladder/urinary dysfunction, erectile dysfunction and pain radiating into the right leg). Accordingly, the appeal in this matter must be denied. Increased Rating for Left Lower Extremity Radiculopathy In general, disability evaluations are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity caused by a given disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Staged ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The Board observes that the words "slight," "moderate," and "severe," are not defined in the Rating Schedule. [An examiner's] use of descriptive terminology such as "mild" by medical examiners, although an element of evidence to be considered by the Board, is not to be dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the degree that its decisions are "equitable and just." 38 U.S.C.A. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. The Veteran's left lower extremity radiculopathy is rated under Code 8521 (for impairment of the external popliteal nerve). 38 C.F.R. § 4.124a. Incomplete paralysis of the popliteal nerve warrants a 10 percent rating when mild, a 20 percent rating when moderate, a 30 percent rating when severe, and a (maximum) 40 percent rating when there is complete paralysis. A review of the record found that at no time during the appeal period have the Veteran's left lower extremity radiculopathy symptoms resulted in more disability greater than mild incomplete paralysis of the external popliteal nerve. Notably, recent (April 2013) VA examination found the Veteran's "left lower extremity radiculopathy previously diagnosed has since resolved." While the record shows earlier clinical notations of radiculopathy (and a notation of paralysis on February 2010 peripheral nerves examination), objective findings included only slight (4/5) motor impairment and no sensory or reflex deficits. [As was noted by the April 2013 VA examiner, the diagnosis of paralysis on this examination is inconsistent with the clinical findings, which included normal EMG study and no evidence of neuropathy or left lumbosacral radiculopathy.] As symptoms (and associated impairment of function) of the left leg radiculopathy shown at no time reflect disability greater than mild incomplete paralysis, a rating in excess of 10 percent is not warranted for any period of time during the evaluation period. The Board acknowledges that the Veteran is competent to describe his observations of the disability, including the subjective symptoms he experiences, such as leg pain, see Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); however, his subjective complaints, with clinical corroboration, are self-serving. He does not point to/identify any specific objective manifestations of the left leg radiculopathy that would warrant characterizing such disability as moderate so as to warrant the next higher (20 percent) rating. Extraschedular Consideration The Board has considered whether referral of this matter for extraschedular consideration is indicated. There is no objective evidence, or even allegation, suggesting that the disability picture presented by the Veteran's service-connected low back disability (with left leg radiculopathy) is exceptional or that schedular criteria are inadequate. There are no symptoms or impairment shown (or alleged) that are not encompassed by the schedular criteria. Consequently, those criteria are not inadequate, and referral for extraschedular consideration is not indicated. See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111 (2008). As was noted above, a July 2005 unappealed (final) rating decision during the pendency of this appeal denied the Veteran a TDIU rating. The recently re-raised claim for TDIU (has been referred to the RO for appropriate action. [Notably, the Veteran is shown to be currently employed full time.] ORDER The appeal seeking separate compensable ratings for neurological manifestations of a low back disability other than the left lower extremity radiculopathy is denied. The appeal seeking a rating in excess of 10 percent for left leg radiculopathy is denied. ____________________________________________ GEORGE R. SENYK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs