Citation Nr: 1326500 Decision Date: 08/20/13 Archive Date: 08/26/13 DOCKET NO. 08-11 144 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado THE ISSUES 1. Entitlement to an increased rating for service-connected cervical spine strain, currently evaluated as 20 percent disabling. 2. Entitlement to an increased rating for service-connected lumbosacral degenerative disc disease and degenerative joint disease without radiculopathy, rated as 10 percent disabling prior to December 1, 2011, and as 20 percent disabling from that date. 3. Entitlement to an initial compensable rating for service-connected right circumflex nerve paralysis. 4. Entitlement to an initial compensable rating for service-connected left circumflex nerve paralysis. 5. Entitlement to extraschedular ratings for the service-connected cervical and lumbosacral spine disabilities. REPRESENTATION Appellant represented by: Jikenna C. Vivens WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. L. Wasser, Counsel INTRODUCTION The Veteran had active service from February 2000 to February 2004. This matter comes before the Board of Veterans' Appeals (Board) from an August 2007 rating decision of the RO in San Diego, California that granted service connection and noncompensable ratings for paresthesias of the right and left upper extremities, effective April 12, 2007, granted an increased 10 percent rating for service-connected degenerative disc disease at L5-S1, effective February 29, 2004, and denied an increase in a 20 percent rating for service-connected cervical spine strain. The Veteran appealed for higher initial ratings for paresthesias of the right and left upper extremities, and for increased ratings for the spine disabilities. In June 2011, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge of the Board (i.e., a Travel Board hearing). A transcript of this hearing is of record. In September 2011, the Board remanded this appeal to the RO via the Appeals Management Center (AMC) for additional development. In an August 2012 rating decision, the AMC granted an increased 20 percent rating for the service-connected lumbosacral spine disability, effective December 1, 2011, and recharacterized this disability as lumbosacral degenerative disc disease and degenerative joint disease without radiculopathy. The AMC has thus assigned "staged" ratings for this disability during the rating period on appeal. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The AMC also recharacterized the service-connected disabilities of both upper extremities as right and left circumflex nerve paralysis. The case was subsequently returned to the Board. In October 2012, the Veteran appointed a new representative before VA. She also stated that in response to the VA's October 2012 letter (which notified her of the award of a 20 percent rating for the lumbosacral spine disability), she wanted to appeal the effective date for this disability. The Board presumes that she meant the effective date of the increased 20 percent rating, and notes that the propriety of the staged disability ratings for this disability are already on appeal. The issue of entitlement to extraschedular ratings for the service-connected cervical and lumbosacral spine disabilities is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's service-connected cervical spine disability is manifested by limitation of motion, with less movement, incoordination and pain on movement, and with guarding or muscle spasm severe enough to result in an abnormal spinal contour, and no ankylosis of the cervical spine. She does not have IVDS resulting in any incapacitating episodes under the governing rating criteria. 2. During the period prior to December 1, 2011, the Veteran's lumbosacral spine disability was manifested by degenerative disc and joint disease of the lumbosacral spine and pain; but, objectively, she had no worse than 70 degrees of forward flexion of her lumbar spine, and the combined range of motion of the thoracolumbar spine was greater than 120 degrees. There also was no evidence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. She does not have IVDS resulting in any incapacitating episodes under the governing rating criteria. 3. During the period from December 1, 2011, the Veteran's low back disability is manifested by degenerative disc and joint disease of the lumbosacral spine, some painful limitation of motion, muscle spasm, tenderness to palpation, and guarding; her remaining functional range of motion is better than 30 degrees of flexion; ankylosis is not shown. 4. Resolving all doubt in the Veteran's favor, throughout the appeal, her right and left circumflex nerve paralysis is manifested by moderate paresthesias of the upper extremities, and no more than moderate incomplete paralysis of the circumflex nerve. CONCLUSIONS OF LAW 1. Throughout the appeal, the criteria are met for an increased higher rating of 30 percent for the service-connected cervical spine disability. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5237, 5242, 5243 (2012). 2. During the period prior to December 1, 2011, the criteria are not met for an increased rating higher than 10 percent for the service-connected lumbosacral spine disability. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5237, 5242, 5243 (2012). 3. During the period from December 1, 2011, the criteria are not met for an increased rating higher than 20 percent for the service-connected lumbosacral spine disability. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5237, 5242, 5243 (2012). 4. Throughout the appeal, the criteria for separate 10 percent ratings for right and left circumflex nerve paralysis are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8518 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided by the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will obtain and assist the claimant in obtaining; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). These VCAA notice requirements apply to all five elements of a claim (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). Further, this notice must include information that a downstream disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id. at 486. Ideally, VCAA notice should be provided prior to an initial unfavorable decision on a claim by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). If it was not, or the notice provided was inadequate, this timing error can be effectively "cured" by providing any necessary VCAA notice and then going back and readjudicating the claim - such as in a statement of the case (SOC) or supplemental SOC (SSOC), such that the intended purpose of the notice is not frustrated and the Veteran is given an opportunity to participate effectively in the adjudication of the claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, an April 2007 notice letter was sent to the Veteran prior to the August 2007 rating decision on appeal, i.e., in the preferred sequence. This letter informed her of the type of information and evidence required to substantiate these claims for increased ratings for cervical and lumbar spine disabilities, and for the initial claim of service connection for the disabilities of the upper extremities, and apprised her of her and VA's respective responsibilities in obtaining this supporting evidence. She was also advised to provide evidence showing that her service-connected disabilities had worsened, so as to in turn entitle her to higher ratings for these disabilities. She was advised of the downstream disability rating and effective date elements of these claims in this letter. See Dingess/Hartman, supra. In addition, a June 2008 letter advised the Veteran of the necessity of providing medical or lay evidence demonstrating the nature and symptoms of her conditions, the severity and duration of the symptoms, and the impact of the conditions and symptoms on her employment. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (VCAA notice in a claim for increased rating need not be "veteran specific"). The claims were most recently readjudicated in a September 2012 supplemental statement of the case. Mayfield IV, supra; Prickett, supra. Moreover, as to the claims for higher initial ratings for service-connected right and left circumflex nerve paralysis (of the upper extremities), in cases, as here, where the claim arose in another context - namely, the Veteran trying to establish her underlying entitlement to service connection for the disability, and her claims have since been granted and an initial disability rating and effective date assigned, the claims as they arose in their initial context has been more than substantiated; indeed, they have been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the initial intended purpose of the notice has been served. Dingess, 19 Vet. App. at 473; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Instead of issuing an additional VCAA notice letter in this circumstance concerning a "downstream" issue, such as the rating assigned for the disability, the provisions of 38 U.S.C.A. § 7105(d) require VA to issue a statement of the case if the disagreement is not resolved. See Goodwin v. Peake, 22 Vet. App. 128 (2008). And this has been done; the Veteran has received both a statement of the case and supplemental statements of the case, discussing the "downstream" disability rating element of her claims, citing the applicable statutes and regulations, and discussing the reasons and bases for initially assigning noncompensable ratings. See Dunlap, supra and VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). As the pleading party attacking the agency's decision, the Veteran, not VA, has the evidentiary burden of proof of showing there is a VCAA notice error in timing or content and that the error is unduly prejudicial, meaning outcome determinative of her claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). There is no such pleading or allegation in this instance. VA also fulfilled its duty to assist the Veteran with these claims by obtaining all potentially relevant evidence, which is obtainable, and therefore appellate review may proceed without prejudicing her. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see also Bernard v. Brown, 4 Vet. App. 384 (1993). To this end, the RO and AMC have obtained her service treatment records (STRs), private medical records, and VA outpatient treatment records, and arranged for VA compensation examinations in May 2007, July 2007, February 2010, and December 2011. Only if the record is inadequate or there is suggestion the current rating may be incorrect is there then a need for a more contemporaneous examination. 38 C.F.R. § 3.327(a) (2012). Here, the most recent VA compensation examinations for these conditions were conducted in December 2011. The mere passage of time since does not, in and of itself, necessitate another examination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). A medical opinion is adequate when it is based upon consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Board finds that the most recent VA examinations are adequate as they provide the information needed to properly rate her service-connected disabilities of the spine and upper extremities. 38 C.F.R. §§ 3.327(a), 4.2. The Board finds that the examination report was sufficiently detailed with recorded history, impact on employment and daily life, and clinical findings. The examination was conducted by competent medical professionals. In addition, it is not shown that the examination was in any way incorrectly conducted or that the VA examiner failed to address the clinical significance of the Veteran's symptoms. Further, the VA examination reports addressed the applicable rating criteria. In this regard, the reports of record contain sufficiently specific clinical findings and informed discussion of the pertinent history and features of the service-connected disabilities to provide probative medical evidence for rating purposes. The Board finds that another examination is not needed since there is sufficient evidence, already on file, to fairly decide these claims. See Caffrey v. Brown, 6 Vet. App. 377 (1994); Olsen v. Principi, 3 Vet. App. 480, 482 (1992); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992); and Allday v. Brown, 7 Vet. App. 517, 526 (1995). As a result, the Board finds that additional development by way of another examination would be redundant and unnecessary. See 38 C.F.R. § 3.326; 38 C.F.R. § 3.327; Green v. Derwinski, 1 Vet. App. 121 (1991). The Board concludes that the appellant was afforded adequate examinations. The Board further finds that the RO has substantially complied with its September 2011 remand orders. In this regard, the Board directed that additional treatment records be obtained and that VA examinations be conducted. Additional VA treatment records dated from 2007 to 2012 have been associated with the claims file, and additional VA examinations have been conducted. Therefore, the Board finds that no further development is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The Board concludes that all the available records and medical evidence have been obtained in order to make a determination as to these claims. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. 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). Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of her claims. At this time, the Board also notes that it is cognizant of the ruling in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. § 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above 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. The Board finds that this was done at the June 2011 Board hearing. Moreover, as discussed above, to the extent possible, VA has obtained the relevant evidence and information needed to adjudicate this appeal. Neither the appellant nor her representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has she identified any prejudice in the conduct of the June 2011 Board hearing. Governing Law and Regulations Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule). Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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. See 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the Veteran's favor. 38 C.F.R. § 4.3. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. When rating a service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). As the Veteran's appeal for higher initial ratings for right and left circumflex nerve paralysis originated from the August 2007 rating decision that granted service connection, she is actually appealing the original assignment of a disability evaluation following an award of service connection. Thus, these two claims actually involve the propriety of the initial disability rating assigned during the entire appeal period. Separate evaluations may be assigned for separate periods of time based on the facts found; the evaluations may be "staged." See Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are also for consideration in the appeals for increased ratings for cervical and lumbosacral spine disabilities. See Hart v. Mansfield, 21 Vet. App. 505 (2007) (finding staged ratings appropriate also in cases where the appeal was not as to the initial rating assigned after service connection is established). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. However, in Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system. Rather, pain may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. Factual Background Private medical records dated in 2004 and 2005 reflect treatment for complaints of persistent neck pain. A November 2004 X-ray study of the cervical spine showed reversal of usual curvature possibly due to muscle spasm, with no fracture or malalignment. A private magnetic resonance imaging (MRI) scan of the spine was performed at University Hospital in January 2005, which showed minimal degenerative disc disease at C5-6 and at L5-S1. There was no evidence of spinal cord compromise or neural compression at any level. In an April 2007 statement, the Veteran stated that she had problems with her shoulders, neck, and numbing of the arms. On VA examination in May 2007, the Veteran complained of neck pain, and numbness and burning on the left side of her neck, which radiated to the right shoulder and low back. She reported constant pain in the center of her neck, and weakness in the right hand on gripping and holding, with pain in the center of her right hand. She also reported tingling and numbness in both shoulders and intermittently on the right side of her neck. She had flare-ups with exertion. She worked as a youth security officer at a youth service center, and reported that she was absent from work for 20 days last year due to her neck disability. She said she had one incapacitating episode in the past year for which she was seen in the emergency room. On examination, there was a slight increase in the normal curvature of the neck, and tenderness throughout the cervical spine in the center, extending to the mid-dorsal level. She also had tenderness in the lumbosacral region but not as severe as the cervical dorsal area. She also had tenderness on both sides of her neck in the paravertebral muscles as well as the medial upper trapezii, bilaterally. There was no swelling or other deformities. Range of motion was as follows: forward flexion from 0 to 35 degrees with pain at the end of the flexion, extension from 0 to 30 degrees with pain, right lateral flexion from 0 to 20 with pain, left lateral flexion from 0 to 45 degrees, right rotation from 0 to 60 degrees with pain, and left rotation from 0 to 80 degrees with pain. Repeat examination times three caused increasing pain but there was no limitation of motion in all the directions. Range of motion of the lumbosacral spine was not performed due to the Veteran's pregnancy. A neurological examination showed deep tendon reflexes within normal limits and equal bilaterally at 2+, and there was no Babinski, no muscle atrophy, and no clonus. Romberg was negative, gait was normal, and an examination of the sensory system showed normal sensation to vibration and fine touch. On examination for pinprick sensation, she complained of hyperesthesia along the center of the spine extending from the base of the head to the mid-dorsal spine, and along both the upper trapezii regions and almost up to the bilateral deltoid regions. There was no hypoesthesia or total numbness. Muscle strength in the shoulders, elbows and wrists was within normal limits. On testing for grip strength in the right hand, there was very minimal weakness compared to the left side. There was no muscle atrophy in the bilateral hands, fingers or interossei. An X-ray study was not done due to her pregnancy. The diagnosis was chronic cervical spine strain, with symptoms of bilateral paresthesias in the shoulders and upper arms, with slight hyperesthesia on pinprick sensation. On VA spine examination in July 2007, the Veteran complained of constant low back pain, and frequent muscle spasms. The pain was worse with prolonged sitting or lying down. She could not sit or stand for prolonged periods. She said the low back pain did not radiate to her legs, but she had constant pain in the anterior thighs and kneecaps, especially in the front. She denied paresthesias in the lower extremities, and denied bladder or bowel incontinence. She did not use assistive devices. She denied incapacitating episodes but said she had severe pain. On examination of the lumbar spine, there was slightly increased lordosis, and tenderness of the lower lumbar region on palpation. There was no swelling or deformity. Range of motion of the lumbar spine was as follows: forward flexion from 0 to 80 degrees, with pain at 70 degrees, extension from 0 to 30 degrees, with pain and stiffness, left and right lateral flexion from 0 to 30 degrees with discomfort, and left and right rotation from 0 to 30 degrees with discomfort. During these motions she complained of neck pain radiating down to the sacral region, and said her whole back hurt. On repeat examination times three, she had pain starting at around 70 degrees by the second forward flexion, and also increasing discomfort. Straight leg raising was negative, and deep tendon reflexes were all active and equal. There was no sensory loss in the lower extremities, with no muscle atrophy, clonus, or weakness. X-ray studies of the cervical and lumbar spine showed muscle spasm in the cervical spine, and a normal lumbosacral spine. The examiner stated that there was slight change with active and passive range of motion during repeat testing, and an additional loss of 10 degrees was seen, especially in flexion of the lumbar spine due to painful motion. There was no weakness, impaired endurance, incoordination, instability or flares. The diagnosis was chronic lumbosacral strain, with slight limitation of motion. VA outpatient treatment records dated from 2007 to 2012 reflect ongoing treatment, including physical therapy, for complaints of neck and low back pain, and reflect diagnoses of polyarthralgia and myofascial pain syndrome. A November 2007 electromyography and nerve conduction study of the right upper extremity was normal; the diagnostic impression was: no evidence of right cervical radiculopathy, carpal tunnel syndrome or ulnar neuropathy. A November 2007 magnetic resonance imaging (MRI) scan of the cervical spine showed no evidence of disc herniation, or foraminal or canal compromise. VA medical records reflect that she has been occasionally seen in the emergency room for flare-ups of neck pain and muscle spasms. On VA spine examination in February 2010, the Veteran reported that she missed 11 days of work in the past 12 months due to neck and low back pain. The Veteran complained of posterior neck pain radiating into the low back with bilateral muscle spasms in the trapezius, right more than left. She denied symptoms in the lower extremities or radiating symptoms referable to the low back. There was no urinary or fecal incontinence. On examination, there was no kyphosis, lumbar flattening, scoliosis, reverse lordosis, or ankylosis of the cervical or lumbar spine. There was lumbar lordosis. There was muscle spasm of the cervical sacrospinalis, with no atrophy, guarding, pain on motion, or weakness, but there was tenderness. There was no muscle spasm of the thoracic sacrospinalis, with no atrophy, guarding, pain on motion, tenderness or weakness. The examiner indicated that there was no muscle spasm, localized tenderness or guarding severe enough to result in abnormal gait or abnormal spinal contour. Reflexes were hyperactive in the bilateral biceps, triceps and brachioradialis, and otherwise normal. Sensation to pinprick was decreased, but full to vibration, light touch, and position sense in the upper and lower extremities. The examiner noted objective findings of bilateral dull sensation with pinprick testing over the volar surface of all fingertips without involvement beyond the distal finger segments, with normal sensation and 2-point discrimination over the same regions. There was normal sensation over the palm and dorsum of the hands and upper arms bilaterally. There was no objective evidence of axillary nerve (circumflex) paralysis, as motor function/strength in shoulder abduction, external rotation and flexion was normal bilaterally. Range of motion of the cervical spine was as follows: flexion from 0 to 40 degrees, extension from 0 to 50 degrees, left and right lateral flexion from 0 to 35 degrees, left lateral rotation from 0 to 55 degrees, and right lateral rotation from 0 to 60 degrees. There was no objective evidence of pain on active range of motion. There were no additional limitations after three repetitions of range of motion. Range of motion of the thoracolumbar spine was as follows: flexion from 0 to 90 degrees, extension from 0 to 25 degrees, left lateral flexion from 0 to 30 degrees, right lateral flexion from 0 to 90 degrees, and left and right lateral rotation from 0 to 30 degrees. There was no objective evidence of pain on active range of motion. There were no additional limitations after three repetitions of range of motion. Sitting straight-leg raise was negative bilaterally. Muscle strength was full in the upper and lower extremities. An X-ray study of the cervical spine showed slight reversal of normal lordosis centered at C5. This was similar to the previous 2007 study. Disc spaces were maintained with subtle degenerative changes of the mid cervical spine. An X-ray study of the lumbar spine showed moderate narrowing of the L5-S1 disc which was probably both developmental and acquired. The posterior elements at L4 and L5 were indistinct and there might be spondylolysis of L5. There was minimal narrowing of the disc space at L4-5. The remaining disc spaces were fairly well maintained. There were mild degenerative changes of the sacroiliac joints. The cervical spine diagnosis was cervical spine degenerative disc disease with residual cervical strain, with no radiculopathy, and residual chronic bilateral trapezius muscle strain. The problem associated with the diagnosis was cervical spine strain and paresthesias right and left upper extremities. There were no significant effects on her usual occupation. The lumbar spine diagnosis was lumbar spine degenerative disc disease/degenerative joint disease with residual lumbar strain, and insufficient reproducible objective findings to support a diagnosis of radiculopathy. The effect on her occupation was increased absenteeism. The examiner diagnosed bilateral upper extremity distal sensory peripheral polyneuropathy of unknown etiology, involving thumbs and all fingertips. The examiner opined that it was less likely than not that the Veteran's fingertip sensory loss was due to or a result of cervical spine degenerative disc disease and strain. At a June 2011 Board hearing, the Veteran stated that she disagreed with the findings of the recent VA compensation examination. Specifically, she felt that her report of pain was not accurately recorded, and that she actually had constant pain which varied in severity. She reported radiating and burning pain of the upper extremities that went "down" to her shoulders, and said she had difficulty gripping files with her right hand. At one point she stated that she had no symptoms in her left arm, but later said she had numbness in that arm. She reported that she missed 12 to 15 days of work in the past 12 months. With respect to her neck, she complained of burning neck pain that went up to her head, and said she could hear a grinding in her neck. She related that sometimes she could not turn her head. She also testified that she had burning, spasming pain in her low back, which did not radiate down to her legs. On VA examination in December 2011, the examiner stated that the claims file had been reviewed, and discussed several pertinent medical records in detail. She noted that the Veteran had been seen in the emergency room in March and May 2011 for right neck muscle pain and spasm. In May 2011, she had normal deep tendon reflexes, sensation and strength. The examiner stated that the Veteran's cervical spine diagnoses were chronic cervical strain, myofascial pain syndrome, and degenerative joint disease without radiculopathy. The thoracolumbar spine diagnoses were lumbosacral degenerative disc disease and degenerative joint disease without radiculopathy, chronic lumbosacral strain, and thoracic degenerative joint disease without radiculopathy. The examiner stated that the Veteran did not have IVDS of the cervical or thoracolumbar spine. The examiner diagnosed bilateral sensory neuropathy of the superior lateral cutaneous nerve, and bilateral sensory neuropathy of a distal cutaneous branch of the lateral supraclavicular nerve. The Veteran complained of constant numbness, tingling and burning pain along the lower neck, upper back, and bilateral shoulders. There was no reported weakness of the lower limbs due to the back condition. The examiner noted that the Veteran is right-handed. The examiner opined that the Veteran's chronic cervical strain and myofascial pain syndrome were moderate to severe. She stated that the Veteran had muscle spasm, with guarding, that was significant enough to alter spinal contour and to restrict range of motion. On physical examination there were spasms that were palpable and visibly apparent, with tender points along the bilateral levator scapulae, upper trapezius, and paracervical spinal musculature. The examiner stated that these findings were consistent with myofascial pain syndrome (MPS), which was a condition distinct from chronic cervical and/or upper thoracic strain. She stated that MPS is a condition of the muscles and their fascia that may become extensive, "spreading" to adjacent muscles and fascia. MPS is characterized by muscle tautness, spasms, pain, and discrete tender points and typically involved the musculature of the neck and upper back, including various cervical and scapular muscles. She opined that when MPS is present in someone who has a history of cervical strain, such as this Veteran, then the MPS is most likely proximately due to or caused by chronic cervical strain which had been inadequately treated. MPS, when moderate to severe, may cause much greater restriction in spine range of motion than what would be expected based on X-ray results alone (as for this Veteran). Additionally, MPS, due to involvement of the muscles/fascia, may cause symptoms of numbness, paresthesias, and burning type pain (as for this Veteran) because distal branches of the nerves that travel near or through the affected muscles become squeezed or compressed, causing symptoms of peripheral neuropathy. The examiner opined that the Veteran's cervical degenerative joint disease was mild, noting the X-ray findings, and the Veteran's normal upper limb deep tendon reflexes and strength. The examiner stated that based on available medical records and the claims file, objective physical examination findings, imaging results, and the Veteran's self-reported history, it was her opinion that the Veteran's degenerative disc disease of the lumbosacral spine was mild, noting that the current X-ray study was normal. On physical examination, she had normal lower extremity sensory and motor findings, intact deep tendon reflexes, and a negative straight-leg raise bilaterally. She walked with a limp, but that was due to an acute ankle sprain, not to the low back disability. With respect to the paresthesias of both upper extremities, the examiner indicated that it was moderate in severity, and that the sensory peripheral neuropathies involving the superior lateral cutaneous nerve (a distal branch of the axillary/circumflex nerve) and the lateral supraclavicular nerve were only mild in severity, based on the absence of objective evidence of motor weakness, atrophy, or fasciculations. She opined that the Veteran's paresthesias (and peripheral neuropathies) were due to her considerable neck and upper back muscular spasm. Anatomically, the supraclavicular nerve passes through the trapezius muscle to supply the skin of the upper and posterior parts of the shoulder, while the axillary/circumflex nerve passes near/through the subscapularis, teres minor, and teres major muscles (which are located on the scapula) and near/through the deltoid muscle. Hence, significant muscle spasm may cause nerve compression or peripheral neuropathy, with symptoms of paresthesias (along with burning pain and numbness, which the Veteran has). With respect to the lumbosacral spine, the Veteran complained of constant middle and low back pain. She also complained of constant stiffness throughout the back, constant spasms of the neck, upper and middle back, and intermittent spasms of the lower back. Range of motion of the cervical spine was as follows: flexion to 25 degrees, extension to 10 degrees, right and left lateral flexion to 15 degrees, and right and left lateral rotation to 35 degrees, with pain at the endpoints. She was able to perform repetitive-use testing, and did not have additional limitation of motion of the cervical spine during this testing, but did have less movement, incoordination, and pain on movement. She had localized tenderness to palpation of the cervical spine, and guarding or muscle spasm severe enough to result in abnormal spinal contour. Range of motion of the thoracolumbar spine was as follows: flexion to 70 degrees, extension to 20 degrees, right and left lateral flexion to 20 degrees, and right and left lateral rotation to 15 degrees, with pain at the endpoints. She was able to perform repetitive-use testing, and did not have additional limitation of motion of the thoracolumbar spine during this testing, but did have less movement, incoordination, and pain on movement. She had localized tenderness to palpation of the thoracolumbar spine, and guarding or muscle spasm severe enough to result in abnormal spinal contour. The examiner indicated that the Veteran had pain at the end of range of motion, and incoordination during range of motion testing, which was attributed to her neck and back disabilities. There was no weakened movement or excess fatigability attributed to her service-connected neck or back disabilities. The examiner opined that the Veteran's pain significantly limited her functional ability during flare-ups and/or with extended use. She reported constant pain and spasms of the neck and back (which were apparent on physical examination). She took multiple medications, and experienced a flare in neck and back symptoms on average once weekly, lasting for a day. She missed approximately 40-50 days of work during the past year, due to combined neck and back symptoms. She worked as a security guard at a youth services/detention center. During some flares, she was unable to tolerate the physical requirements of her job. Due to her use of medication and limitation of spine motion (she was unable to look over her shoulder) because of pain and spasms, she avoided driving during flares. A June 2012 VA outpatient treatment record reflects that the Veteran complained of numbness and tingling of her right hand and fingers; she was given wrist splints in July 2012. In June 2012 she reported that her neck pain had improved significantly. Cervical and Lumbar Spine Disabilities Initially, the Board notes that the Veteran's service-connected right and left circumflex nerve paralysis is separately rated. Symptoms related to these disabilities may not be considered while evaluating the service-connected cervical spine disability. See 38 C.F.R. § 4.14. Throughout this appeal, the Veteran's service-connected cervical spine disability has been rated as 20 percent disabling under Diagnostic Code 5237, pertaining to cervical strain. The service-connected lumbosacral spine disability was rated as 10 percent disabling prior to December 1, 2011, and from that date as 20 percent disabling, under Diagnostic Code 5243, pertaining to intervertebral disc syndrome (IVDS). Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). Under the General Rating Formula for Diseases and Injuries of the Spine, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease: A 10 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent evaluation is warranted where there is forward flexion of the cervical spine of 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. The Notes following the General Rating Formula for Diseases and Injuries of the Spine provide further guidance in rating diseases or injuries of the spine. Note (1) 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. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2012). Note (2) provides that, 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. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. See also Plate V, 38 C.F.R. § 4.71a . 38 C.F.R. § 4.71a , Diagnostic Codes 5235-5243 (2011). Note (3) provides that, 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. 38 C.F.R. § 4.71a (2012). Note (4) provides that the rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a (2012). Note (5) provides that, 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. 38 C.F.R. § 4.71a (2012). Note (6) provides that disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a (2012). Under Diagnostic Code 5243, intervertebral disc syndrome or disc disease, may be rated under the General Rating Formula for Diseases and Injuries of the Spine, which includes combining separate evaluations of the chronic orthopedic and neurologic manifestations, or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, which are rated on the total duration of incapacitating episodes over the past 12 months, whichever results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, if there are incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months, a 10 percent rating is warranted. If there are incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months, a 20 percent rating is warranted. If there are incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months, a 40 percent rating is warranted. If there are incapacitating episodes having a total duration of at least six weeks during the past 12 months, a 60 percent rating is warranted. 38 C.F.R. § 4.71a (2012). Note 1 to the Diagnostic Code 5243 defines an incapacitating episode as a period of acute signs and symptoms that requires bed rest prescribed by and treatment by a physician. Supplementary Information in the published final regulations states that treatment by a physician would not require a visit to a physician's office or hospital but would include telephone consultation with a physician. If there are no records of the need for bed rest and treatment, by regulation, there are no incapacitating episodes. 38 C.F.R. § 4.71a (2012). Ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992). Having carefully considered the Veteran's contentions in light of the evidence of record and applicable law, and for the reasons and bases discussed below, the Board finds that her service-connected cervical spine disability is more appropriately evaluated as 30 percent disabling throughout the rating period on appeal. In this regard, the evidence documents limitation of motion, with less movement, incoordination and pain on movement, and with guarding or muscle spasm severe enough to result in an abnormal spinal contour. Although the forward flexion of the cervical spine has not been reported at 15 degrees or less, the Board finds that with consideration of the additional DeLuca factors, the Veteran's disability picture as it relates to her cervical spine more nearly approximates the criteria required for a 30 percent rating. 38 C.F.R. §§ 4.3, 4.7. However, there is no ankylosis of the cervical spine, and thus, a higher 40 percent schedular rating is not warranted for this disability under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2012). On VA examinations in 2007, 2010, and 2011, limited cervical spine motion was demonstrated, along with pain on motion, localized tenderness to palpation of the cervical spine, and guarding or muscle spasm severe enough to result in abnormal spinal contour along with incoordination on movement. As to the lumbosacral spine disability, the Board finds that it is appropriately evaluated as 10 percent disabling prior to December 1, 2011, and as 20 percent disabling from December 1, 2011 (the date of the VA examination that showed muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour). During the period prior to December 1, 2011, the VA examinations in July 2007 and February 2010 did not show forward flexion of the thoracolumbar spine to 60 degrees or less, a combined range of motion of the thoracolumbar spine of 120 degrees or less, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. To the contrary, her forward flexion during this period was to 80 degrees (with pain at 70 degrees) in July 2007, and to 90 degrees in February 2010. Even on examination in December 2011, forward flexion was no worse than 70 degrees. In sum, throughout the rating period prior to December 1, 2011 forward flexion has not been worse than 70 degrees, and range of motion or joint function was not additionally limited by pain (other than the 10 degrees mentioned above), fatigue, weakness, lack of endurance or incoordination following repetitive use. Lumbosacral muscle spasms were not noted on VA examination in July 2007. On VA examination in February 2010, there was no muscle spasm, localized tenderness or guarding severe enough to be responsible for abnormal gait or abnormal spinal contour. An increased 20 percent rating is not warranted for the lumbosacral spine disability during the period prior to December 1, 2011 under the General Rating Formula. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2012). The Board finds that during the period since December 1, 2011, an increased 40 percent rating is not warranted for the lumbosacral spine disability, as the evidence does not show forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. On VA examination of December 1, 2011, flexion was performed to 70 degrees, with pain at 70 degrees. In other words, forward flexion was no worse than 70 degrees, even with consideration of pain. And since there is degenerative disc disease in the cervical and lumbosacral spine, the Board also has considered whether a higher rating is warranted via application of Diagnostic Code 5243. However, the December 2011 VA examiner has explicitly stated that the Veteran does not have intervertebral disc syndrome (IVDS) of the cervical or thoracolumbar spine. Further, although there is clear evidence of degenerative disc disease, there is no evidence of incapacitating episodes that meet the above regulatory definition. As such, Diagnostic Code 5243 cannot serve as grounds for increasing the rating for her cervical or lumbosacral spine disabilities. There are no other relevant code sections for consideration. As for separate evaluations of the chronic neurologic manifestations associated with her cervical spine disability, as noted above, additional separate neurological ratings have already been awarded for radiculopathy of both upper extremities. The Board has also considered whether a separate evaluation is warranted for neurological symptoms associated with the Veteran's service-connected degenerative joint disease and degenerative disc disease of the lumbosacral spine throughout the rating period on appeal. In this regard, as discussed above, Note (1) of the general rating formula instructs the rater to separately evaluate any associated objective neurological abnormalities under an appropriate diagnostic code. In the present case the Board notes that the medical evidence of record reveals no significant chronic neurological abnormalities due to the service-connected lumbosacral spine disability. Several neurological examinations of the lower extremities were normal. Specifically, strength, sensation and reflexes were all normal in the lower extremities and straight leg raise was negative on nearly every examination. The Veteran has denied radicular symptoms in the lower extremities. Given the foregoing, the overall evidence reveals an essentially normal neurologic disability picture throughout the entire rating period on appeal. Accordingly, assignment of a separate evaluation for neurologic manifestations of the lumbosacral spine disability is not warranted here. Right and Left Circumflex Nerve Paralysis of the Upper Extremities The RO has rated the service-connected right and left circumflex nerve paralysis as noncompensable for each upper extremity, under Diagnostic Codes 8599-8518, pertaining to paralysis of the circumflex nerve. Under 38 C.F.R. § 4.124a, Diagnostic Code 8518, incomplete paralysis of the circumflex nerve of the major or minor arm is rated noncompensable when mild and 10 percent when moderate; a 30 percent or 20 percent rating is warranted for severe incomplete paralysis of the major or minor hand, respectively; and a 50 percent or 40 percent rating is warranted for complete paralysis of the major and minor hand, respectively, where abduction of the arm is impossible, outward rotation is weakened, and muscles supplied are deltoid and teres minor. Diagnostic Code 8618 contemplates neuritis of this nerve, and Diagnostic Code 8718 contemplates neuralgia of this nerve. 38 C.F.R. § 4.123 indicates that neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.124 indicates that neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical destruction so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. Tic douloureux, or trifacial neuralgia, may be rated up to complete paralysis of the affected nerve. Throughout the rating period on appeal, the medical evidence consistently shows complaints of burning, tingling and numbness extending from the neck to the shoulders and upper extremities. On VA examination in May 2007, hyperesthesia was seen along the center of the spine extending from the base of the head to the mid-dorsal spine, and along both the upper trapezii regions and almost up to the bilateral deltoid regions. A November 2007 electromyography and nerve conduction study of the right upper extremity was normal; the diagnostic impression was no evidence of right cervical radiculopathy, carpal tunnel syndrome or ulnar neuropathy. On VA examination in February 2010, reflexes were hyperactive in the bilateral biceps, triceps and brachioradialis, and sensation to pinprick was decreased. The examiner stated that there was no objective evidence of axillary nerve (circumflex) paralysis, as motor function/strength in shoulder abduction, external rotation and flexion was normal bilaterally. The examiner found no radiculopathy. On VA examination in December 2011, the examiner opined that the Veteran had MPS that was due to the service-connected chronic cervical strain, and that her MPS caused symptoms of numbness, paresthesias, and burning type pain. The examiner diagnosed bilateral sensory neuropathy of the superior lateral cutaneous nerve, and bilateral sensory neuropathy of a distal cutaneous branch of the lateral supraclavicular nerve. The examiner indicated that the paresthesias of both upper extremities were moderate in severity, and that the sensory peripheral neuropathies involving the superior lateral cutaneous nerve (a distal branch of the axillary/circumflex nerve) and the lateral supraclavicular nerve were only mild in severity, based on the absence of objective evidence of motor weakness, atrophy, or fasciculations. She opined that the Veteran's paresthesias (and peripheral neuropathies) were due to her considerable neck and upper back muscular spasm. After a review of the record, and in light of the examiner's description of the symptoms shown on examination indicating a moderate degree of severity and specifically paresthesias, the Board finds that during this period, higher separate 10 percent ratings more nearly approximate the Veteran's disability picture and that higher evaluations are warranted throughout the rating period on appeal. 38 C.F.R. § 4.7. An even higher rating is not warranted, as there is no lay or medical evidence that the Veteran's paresthesias cause functional impairment of any movement of the Veteran's upper extremities. There is no muscle atrophy or motor weakness. As such, no more than a moderate disability is demonstrated, and higher separate 10 percent ratings are assigned under Diagnostic Code 8518 for the service-connected right and left circumflex nerve paralysis. ORDER An increased schedular rating for the cervical spine disability of 30 percent is granted, subject to the laws and regulations governing the payment of monetary benefits. During the period prior to December 1, 2011, an increased schedular rating in excess of 10 percent for the low back disability is denied. During the period from December 1, 2011, an increased schedular rating in excess of 20 percent for the low back disability is denied. Higher separate 10 percent ratings for service-connected right and left circumflex nerve paralysis are granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND The Board does not have the authority to assign an extraschedular rating in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001); see also Bagwell v. Brown, 9 Vet. App. 337, 339 (1996); VAOPGCPREC 6-96 (August 16, 1996). An extraschedular rating must be requested by the RO and approved by the Under Secretary for Benefits or by the Director of the Compensation Service. As to consideration of referral for an extraschedular rating for the cervical and lumbosacral spine disabilities, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The Board notes that at the December 2011 VA examination it was reported that the Veteran has missed 40 or 50 days of work during the past year due to her service-connected neck and back disabilities. Thus, the Board finds that the evidence suggests that an exceptional or unusual disability picture is presented in this case that warrants further development and possible referral of these claims to the Director of Compensation and Pension Service or the Under Secretary for Benefits for consideration of an extraschedular evaluation as to these disabilities. 38 C.F.R. § 3.321(b)(1). Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran submit documentation that her service-connected cervical and lumbar spine disabilities have resulted in marked interference with her employment. In this regard, she may also submit medical documentation and employment related records documenting the 40 to 50 days that she missed work in 2011 due to service-connected neck and back disabilities. 2. If the Veteran submits evidence that her service-connected disabilities have resulted in marked interference with employment, refer the claims for increased ratings for the cervical spine and lumbosacral spine disabilities to the Director of Compensation and Pension Service or the Under Secretary for Benefits for consideration of a possible extraschedular evaluation as to these disabilities. 38 C.F.R. § 3.321(b)(1). 3. Then readjudicate these claims for increased ratings on an extraschedular basis. If any benefit sought on appeal remains denied, the Veteran and her representative should be furnished a supplemental statement of the case and given the opportunity to respond. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs