Citation Nr: 1326718 Decision Date: 08/21/13 Archive Date: 08/29/13 DOCKET NO. 04-28 783 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a cervical spine disability (neck disability), to include as secondary to a service-connected low back disability (back disability). 2. Entitlement to a disability rating in excess of 20 percent for radiculopathy of the right lower extremity associated with the low back disability. 3. Entitlement to a disability rating in excess of 20 percent for radiculopathy of the left lower extremity associated with the low back disability. 4. Entitlement to an effective date earlier than January 18, 2012 for the grant of service connection and assignment of a 20 percent disability rating for radiculopathy of the right lower extremity associated with the low back disability. 5. Entitlement to an effective date earlier than January 18, 2012 for the grant of service connection and assignment of a 20 percent disability rating for radiculopathy of the left lower extremity associated with the low back disability. 6. Entitlement to an effective date earlier than January 18, 2012 for the assignment of a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). 7. Entitlement to an effective date earlier than January 18, 2012 for the assignment of a 10 percent disability rating for hemorrhoids. 8. Entitlement to an effective date earlier than January 18, 2012 for the grant of dependents' Educational Assistance benefits. 9. Entitlement to a disability rating in excess of 40 percent for the service-connected low back disability. 10. Entitlement to a disability rating in excess of 10 percent for the service-connected tinnitus. 11. Entitlement to a disability rating in excess of 10 percent for the service-connected left shoulder bursitis. 12. Entitlement to a compensable disability rating for the service-connected bilateral hearing loss. 13. Entitlement to a compensable disability rating for a scar of the right inguinal region. REPRESENTATION Appellant represented by: Sean A. Ravin, attorney ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from March 1966 to April 1986. The appeal of the denial of service connection for a low back disability comes before the Board of Veterans' Appeals (Board) from a January 2010 Order of the United States Court of Appeals for Veterans Claims (Veterans Court). That appeal originates from an October 2002 rating decision of the RO in New Orleans, Louisiana. The appeal as to all other issues comes to the Board from an October 2012 rating decision of the RO in Roanoke, Virginia, which now retains original jurisdiction over the Veteran's claims file. In a decision dated in September 2007, the Board denied service connection for a low back disability (back disability). The Veteran appealed that decision to the Veterans Court. In an Order dated in March 2009, pursuant to a Joint Motion of the parties for Remand (Joint Motion), the Veterans Court vacated the Board's September 2007 decision and remanded the issue back to the Board. In a May 2009 decision, the Board again denied service connection for a low back disability. The Veteran appealed that decision to the Veterans Court. In January 2010, the Veterans Court granted a Joint Motion for Remand, vacated the May 2009 decision and remanded the issue to the Board for compliance with the Joint Motion. In November 2010, the Board remanded the issue of entitlement to service connection for a low back disability for additional evidentiary development. It has since been returned to the Board for further appellate action. In reviewing this case the Board has not only reviewed the physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. The issues of (1) entitlement to a disability rating in excess of 20 percent for right lower extremity radiculopathy, (2) entitlement to a disability rating in excess of 20 percent for left lower extremity radiculopathy, (3) entitlement to an effective date earlier than January 18, 2012 for the grant of service connection and assignment of a 20 percent initial rating for right lower extremity radiculopathy, (4) entitlement to an effective date earlier than January 18, 2012 for the grant of service connection and assignment of a 20 percent initial rating for left lower extremity radiculopathy, (5) entitlement to an effective date earlier than January 18, 2012 for the assignment of a TDIU, (6) entitlement to a disability rating in excess of 10 percent for hemorrhoids, (7) entitlement to an effective date earlier than January 18, 2012 for the assignment of a 10 percent rating for hemorrhoid, (8) entitlement to a disability rating in excess of 40 percent for a low back disability, (9) entitlement to a disability rating in excess of 10 percent for tinnitus, (10) entitlement to a disability rating in excess of 10 percent for a left shoulder disability, (11) entitlement to a compensable disability rating for bilateral hearing loss, and (12) entitlement to a compensable disability rating for a scar of the right inguinal region are addressed in the REMAND below and are therein REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the issue herein decided has been accomplished. 2. While arthritis is listed among the diseases for which the presumption of service connection for certain chronic diseases, and the provisions regarding chronicity in service and continuity of symptomatology after service must be considered, degenerative disc disease is not listed. 3. The Veteran did not sustain a cervical spine injury or disease in service. 4. Symptoms of cervical spine arthritis were not chronic in service. 5. Symptoms of cervical spine arthritis have not been continuous since service separation. 6. No current cervical spine disability is related to service or to any service-connected disability. 7. No current cervical spine disability was worsened beyond its natural progress by any service-connected disability. CONCLUSION OF LAW A cervical spine disability was not incurred in service; cervical spine arthritis is not presumed to have been incurred in service; a cervical spine disability is not proximately due to or a result of any service-connected disability. 38 U.S.C.A. §§ 337, 1101, 1110, 1112, 1113, 1131, 1153, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veterans Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Certain specific conditions are considered chronic diseases under VA Law. These include arthritis, but do not include degenerative disc disease. 38 C.F.R. § 3.309(a). Where arthritis is shown to be chronic in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic arthritis in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When arthritis is established, there is no requirement of evidentiary showing of continuity. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required only where arthritis noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Where a veteran served 90 days or more during a period of war or after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran alleges that his current cervical spine disability is due either to the in-service motor vehicle accident that caused his service-connected low back disability or to the low back disability itself. After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that no cervical spine disability is related to service, and no cervical spine disability is related to or aggravated by any service-connected disability. As set out above, this appeal involves a lengthy procedural history dating back more than a decade. The 4 volumes that comprise the claims file include a large number of pertinent clinical records, notations, test results, and medical opinions, as well as written assertions from the Veteran and his attorney. These records paint an inconsistent picture as to the history of the Veteran's cervical spine complaints and the onset of a current cervical spine disability. The Board will address this evidence in detail, but will note at the outset of this discussion that, to a significant degree, the Board's decision here is based on a credibility determination. In other words, the Board finds that the pertinent details of the Veteran's assertions as to the history of his cervical spine symptoms are sometimes inaccurate. There is no question regarding the fact that the Veteran was involved in a motor vehicle accident in June 1979, while he was in the service, more than 30 years ago. The Veteran's service treatment records document this accident, as well as the treatment provided to the Veteran subsequent to the accident. Notably, there were no cervical spine symptoms reported coincident with the accident, and there were no cervical spine injuries found. The June 6, 1979 ER report (in some records reported as July 1979) shows that the Veteran complained of bruises and abrasions of the left leg and side with a few minor cuts on the hand and elbow. The service treatment reports show that, subsequent to the Veteran's motor vehicle accident, the Veteran received treatment for back pain and other conditions, and that multiple assessments of low back pain were rendered. However, they do not reflect any complaints or findings specific to the cervical spine. Reports in 1980 and 1981 reflect that the Veteran gave an affirmative response to whether he had chronic joint pain (back, neck, arm, leg), but that he specified "lower back problems" on the 1980 report and underlined the word "back" on the 1981 report. A January 1981 medical assessment addressed to an attorney representing the Veteran at the time, and based on information extracted from the Veteran's official medical records, is negative for complaints, symptoms, findings or diagnoses relating to the cervical spine, but notes low back pain and possible leg injury, providing highly probative evidence against this claim given the time it was taken and the results. The Board attaches substantial probative weight to the reports coincident with the motor vehicle accident: It is at this time that his treatment providers were attempting to determine the extent of his injuries and his overall physical condition. It is reasonable to expect that such reports would contain all pertinent complaints, and all pertinent abnormalities found, so that his treatment providers would have an accurate picture in prescribing a plan of care. Moreover, the Veteran's assertions, as related to treatment providers during this period are given greater weight than accounts of his injuries made at any subsequent time. This is a simple acknowledgment of the shortcomings of memory. In addition, the Board must also consider the self-interest involved in accounts of the injury made in pursuit of a claim for disability benefits. The Board may properly consider the personal interest a claimant has in his or her own case, but the Board is not free to ignore his assertion as to any matter upon which he is competent to offer an opinion. See Pond v. West, 12 Vet. App. 341, 345 (1999); and see Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board will discuss these factors in more detail below. Simply put, the lack of complaints regarding the cervical spine and neck at the time of the accident, and the lack of clinical findings regarding the cervical spine during post-accident examinations is more convincing as to the Veteran's symptomatology at the time of the accident than are his later assertions made in pursuit of the current claim for benefits. In summation of the findings pertinent to service, the Veteran was involved in a motor vehicle accident in which he injured his low back; however, there were no pertinent complaints or findings regarding the cervical spine. This is persuasive evidence that there was no injury or disease of the cervical spine, and that the Veteran was not experiencing symptomatology of the cervical spine. The January 1986 service separation examination shows that the Veteran's neck and spine were normal on clinical evaluation, with a notation of recurrent back pain. No pertinent cervical spine history, defects, or diagnoses were noted. The report of medical history reflects no complaints of cervical spine symptoms, or a cervical spine diagnosis. The medical history as recorded by the examiner was degenerative joint disease in the left shoulder, frequent headaches, hearing loss, sinusitis, skin disease, leg cramps, stomach trouble, recurrent back pain, vision defect, and hemorrhoids. To the extent there were cervical spine or neck symptoms at any time in service, the Board finds that there was no cervical spine disability in service, and the Veteran's cervical spine was normal at service separation. Turning to the post-service medical evidence, the Board notes that a July 2011 VA examiner only diagnosed degenerative disc disease of the cervical spine. There were no other diagnoses; however, an X-ray in April 1998 a C5-6 herniated nucleus pulposus/osteophyte. An April 2009 note from the Veteran's private physician, Dr. Neumann includes a reference to arthritic changes. In any event, to the extent that there is current arthritis of the cervical spine in this case, the first findings were not made until 1998, and the Board finds that arthritis did not become manifest to a compensable degree within one year after the Veteran's service separation in April 1986, and symptoms of arthritis were not continuous after service. The Board acknowledges that symptoms of arthritis and the manifestation of arthritis to a compensable degree each share two essential components: clinical evidence of arthritis, such as an X-ray finding, and musculoskeletal impairment, such as pain associated with joint motion. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012) (establishing a compensable rating for X-ray evidence of arthritis and limited or painful motion). In this case, there are no positive X-ray findings until 1998. The Veteran's assertions of neck pain during this period will next be addressed in detail; however, the Board's finding is that his assertions as to experiencing neck pain prior to 1998 are inaccurate. Regarding the onset of cervical spine symptomatology, the Veteran has made conflicting assertions. The report of a September 1998 VA spine examination shows that the Veteran asserted that he had mild pain in the back of the neck since 1979. The diagnosis was a recurrent cervical strain. The report of a January 1999 VA spine examination shows that the Veteran reported a history of a June 1979 motor vehicle accident; however, the examiner also noted that the Veteran began to experience pain in the cervical spine "a few years ago." The relevant diagnoses were cervical spine disc disease with possible mild cord compression, and radiculopathy of both the cervical and lumbosacral spine. A June 2002 private medical report shows that the Veteran reported that he had neck pain since 1998. The diagnosis was cervical myelopathy of unknown onset. A self-history report dated March 2008 from the Reconstructive Spine Center notes onset of lumbar back pain in 1979 and onset of severe neck pain in early 2007. The Veteran went on to specify the date of onset of neck pain as January 2007, and that this was the first time he had experienced these symptoms. Records from Dr. Mody dated April 2008 reveal a 1-year history of neck and right arm complaints, which is again inconsistent with the above. A March 2008 report reveals that the Veteran denied major trauma preceding the onset of symptoms. In April 2008, the Veteran underwent an anterior cervical decompressive discectomy at C5-6, and an anterior cervical fusion at C5-6 and C5-7. Thus, aside from the September 1998 report, the Veteran has asserted consistently to treatment providers that his neck pain began well after service. After a review of all of the evidence, the Board is persuaded that there were no significant cervical spine symptoms until 1998, at best. Weighed against the September 1998 reference to mild pain in the back of the neck since 1979 is the Veteran's behavior during this period. The current claim is not the first claim for disability compensation filed by the Veteran since service separation. In October 1986, the Veteran filed a claim seeking service connection for multiple disabilities, including a back condition, hearing loss, tinnitus, cysts, warts, benign tumors, sinusitis, a shoulder condition, leg cramps, and hemorrhoids, as disabilities related to service. He did not mention a neck or cervical spine disability or symptoms thereof, a somewhat significant omission particularly in light of the detail of his claim, which included, at that time, warts. The Veteran filed an increased rating claim in September 1987 but did not mention any issues with his cervical spine or neck. While inaction for many years regarding filing a claim is not necessarily indicative of the absence of symptomatology, where, as here, a veteran takes action regarding other claims, it becomes reasonable to expect that the Veteran is presenting all issues for which he is experiencing symptoms that he believes are related to service. In other words, the Veteran demonstrated as early as October 1986 that he understood the procedure for filing a claim for VA disability compensation. The Veteran followed that procedure listing 10 other claimed disabilities. It is reasonable to interpret this as a complete reporting of symptomatology believed to be related to service. Thus, the Veteran's inaction regarding a claim for a cervical spine disability, when viewed in the context of action regarding 10 other claims, is interpreted as indicative of the lack of cervical or neck symptomatology at that time, providing evidence against his current view that he has had this problem since service. In addition, the Veteran was afforded a comprehensive examination in December 1986, in conjunction with his service connection claim. There was no diagnosis of a cervical spine disability, and no complaint of associated symptoms. A VA examination was also conducted to evaluate the 1987 increased rating claim; however, no pertinent findings or complaints regarding the cervical spine were noted. A routine future examination was conducted in January 1991; and, while shoulder and back pain were discussed at length, the Veteran did not report any neck or cervical spine symptoms. There were also no pertinent findings or diagnoses. An October 1996 VA medical certificate indicates complaint of a history of back condition for a long time. There is no mention of neck pain. Subsequent treatment records in 1996 and 1997 document ongoing treatment for the low back, but there is no mention of cervical spine problems. Of particular significance in the Board's finding that there was no cervical spine or neck symptomatology until 1998, a March 1997 private treatment report specifically notes that the Veteran "denies posterior neck pain or upper back pain." At this moment, it is the Veteran providing factual evidence against his own claim. In addition, a treatment note dated April 14, 1997 indicates that the Veteran underwent a total CT myelogram (cervical, thoracic, lumbar) which was recorded as normal. A private treatment report dated in May 1997 shows treatment for low back complaints. There is no mention of neck pain. In short, the Veteran had multiple opportunities to report cervical spine symptomatology to VA for purposes of compensation, and to private and VA treatment providers for purposes of treatment, but despite reporting numerous other conditions, he did not report cervical spine symptoms, indeed, he specifically denied cervical spine symptoms, and his treatment providers did not find any cervical spine abnormality throughout the post-service period, prior to 1998. A progress note dated February 4, 1998 reveals the Veteran's account that he had been dropping things more frequently over past 12 to 18 months. The physician noted cervical myelopathy, severe. A cervical MRI was performed in April 1998 and revealed possible mild cord impingement at C5-6 level due to mild posterior midline right paramedial disc protrusion at this level. X-rays of the cervical spine were normal. An April 1998 Neurosurgery Clinic New Patient note reveals that the Veteran was complaining of neck pain. Radiology findings were read as showing a C5-6 herniated nucleus pulposus/osteophyte. The impression was cervical myelopathy. Thus, the initial reports of cervical spine symptomatology place the onset of symptoms a few months prior to February 1998. This underscores the Board's finding that, contrary to the Veteran's assertion to the September 1998 VA spine examiner that he had mild pain in the back of the neck since 1979, the weight of the evidence demonstrates that onset of symptoms is strongly correlated to the February 1998 progress note. Prior to this note, there were no cervical spine complaints reported by the Veteran, and there were no clinical abnormalities noted. The Board emphasizes this multi-year gap between service separation (1986) and initial reported symptoms related to a cervical spine disability in 1998 (a gap of greater than 20 years). See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability). There is no question that the Veteran is competent to report the onset of symptoms. In general, laypersons can attest to factual matters of which they have first-hand knowledge, such as experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a lay person is competent to identify the medical condition (noting that sometimes the lay person will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011) ((lay persons are competent to provide opinions on some medical issues). In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether the evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21. Vet. App. 303 (2007). Here, the Board's finding that the onset of cervical spine symptoms and a cervical spine disability corresponds to the February 1998 treatment report is not based on any lack of competence on the Veteran's part to identify the onset of the disability. Rather, it is based on a credibility determination, i.e., that he is an inaccurate historian of his disabilities from so many years ago. Nevertheless, service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Board thus turns to the opinion evidence addressing service incurrence. A letter from private physician Dr. Neumann dated in April 2009 notes that Dr. Neumann has been the Veteran's physician for over fifteen years, and he has performed many clinical evaluations on the Veteran. The Veteran was involved in a motor vehicle accident in June. 1979. His back has caused him serious difficulty since that date. His military records and a current evaluation confirm a prolonged and painful condition which has been a negative influence on his ability to be employed and also his quality of life. He is obviously disabled due to disorders of the back as indicated by a Social Security judge in 1998 and has been unemployable since 1995. A review of his medical records reveals the following remarkable events: 1. Lower back surgery in August. 1998; 2. Left shoulder surgery in April. 2004; 3. Right shoulder surgery in October. 2005; 4. Neck surgery in May, 2008. The etiology of all these events is most likely due to slow deterioration and arthritic changes from trauma suffered in the aforementioned motor vehicle accident of June, 1979. An August 2008 letter from private physician Dr. Picou reveals that she was asked by the Veteran to review his military and VA medical records in regard to his back condition. She noted that the military records looked to be fairly complete, while the VA records were sketchy, but sufficient to formulate a medical opinion. According to Dr. Picou, military records clearly reveal a history of severe chronic back problems arising from a motor vehicle accident in 1979. There was no record of a problem in the cervical area at the time of the accident. A March 1997 X-ray of the cervical spine revealed abnormalities. In the spring of 1997, the Veteran was diagnosed with severe cervical myelopathy. During a September 1998 VA spine evaluation, the Veteran was diagnosed with recurrent cervical strain after complaining of back and neck pain since 1979. During a January 1999 VA spine examination, the Veteran was diagnosed with degenerative joint disease and nerve root compression, cervical spine disease with possible mild cord compression, and radiculopathy of both the cervical and lumbosacral spine. The VA examiner noted that the etiology of the L4-L5 disk herniation was likely the result of the in-service motor vehicle accident. Dr. Picou noted that, in June 2002, the Veteran complained of neck pain since 1998; however, she also noted that the records indicate that complaints of neck pain began in 1997. She reasoned that this does not mean that his problem was onset at this time, and that a patient who is in severe pain (in this instance in the lower back) will not necessarily complain about a lesser pain elsewhere. Her conclusion was that the cervical condition seems to be a result of textbook post-traumatic whiplash syndrome. A March 2011 letter from private physician Dr. Rowe notes that she had recently gotten to know the Veteran as a patient. The Veteran brought in previous records for review. Amongst these were letters from Dr. Neumann, and Dr. Picou. They clearly were quite familiar with his case. Dr. Rowe noted that their detailed reports which were compiled from review of the original record are quite compelling. Dr. Rowe noted that she has no records of the Veteran's care prior to the accident of 1979, and she thinks it is at least as likely as not (a 50% or greater probability) that his cervical spine disease is post-traumatic in nature. This is consistent with his stated history as well. The July 2011 VA examiner opined that degenerative disc disease of the cervical spine is less likely as not (less than 50/50 probability) caused by or a result of an in-service illness, injury or event, including the automobile accident of 1979, the lumbar spine disability or the lumbar spine surgery. The examiner found that it is less likely than not that the Veteran's remote history of a motor vehicle accident caused or contributed to the Veteran's cervical degenerative disc disease or was caused or aggravated by the Veteran's lumbar microdiskectomy. The VA examiner reviewed the findings of Dr. Neumann, who she noted was not Veteran's treating physician at the time of the motor vehicle accident. As the service treatment records do not document any cervical complaints or diagnoses, the examiner surmised that any additional information Dr. Neumann may have used in forming an opinion would have come from the Veteran's subjective report of his personal memories and complaints. The examiner noted that Dr. Neumann's letter fails to address the question of the diagnosis of cervical myelopathy and how that may or may not be related to a remote history of a motor vehicle accident. According to the examiner, the question at hand currently is not the Veteran's back issues, which are well documented in the record. She found that Dr. Neumann's letter fails to add any new insight about the cause of the cervical condition and how it may or may not be related to the motor vehicle accident, to the Veteran's back problems, or to the surgery for back problems. The examiner found, in short, that Dr. Neumann's opinion appears to be based on the subjective claims of the Veteran versus any objective findings, and that there is nothing objective in Dr. Neumann's letter which would tie the cervical pathology to the lumbar pathology or to the motor vehicle accident in question. The VA examiner also addressed the letter from Dr. Picou. The examiner noted the assertion of Dr. Picou that there was no record of a problem in the cervical area at the time of the accident and that the records indicate that complaints of neck pain began in 1997 and continued until January 2007. In regard to Dr. Picou's opinion that the onset of neck problems could have been prior to 1997, as a patient who is in severe pain (lower back) will not necessarily complain about a lesser pain (neck) elsewhere, the VA examiner noted that Dr. Picou herself found there was no problem with the neck at the time of the accident and that the first documented neck problems were 18 years after the motor vehicle accident. The examiner reasoned that Dr. Picou's argument that an individual might have a lesser pain that is masked or overshadowed by a more significant pain is insufficient to explain the amount of time between the motor vehicle accident and onset of neck complaints "with 50 percent or more confidence." According to the VA examiner, an assumption of injury with no complaints at the time of accident or for years afterward and with no objective findings on physical examinations performed in service point to a lack of cervical injury or condition during service. There are 18 years of intervening time where cumulative biomechanical stresses on the cervical spine were acting on the neck and contributing to the resulting cervical spine pathology. The VA examiner acknowledged that the Veteran denied other injuries to the neck, but noted that daily wear and tear without noticeable injury can contribute to cervical spine pathology insidiously. She also noted that a disc protrusion can occur without a known injury also and this is more likely to have occurred at the time of onset of neck and upper extremity symptoms. The examiner noted that the Veteran did not have cervical spine surgery until 2008, according to Dr. Neumann's letter, which is nearly 30 years after the motor vehicle accident. With that much intervening time, there is no plausible mechanism tying the cervical condition necessitating surgical intervention to the remote history of auto accident without documented neck injury at the time of accident. The Board interjects that the VA examiner's finding that Dr. Picou's argument is not sufficient to explain the amount of time between the motor vehicle accident and onset of neck complaints "with 50 percent or more confidence" appears to misstate the standard of proof in VA claims. Evidence in favor of the Veteran's claim is not held to such a higher standard of proof, but need only be in approximate balance with evidence against the claim. However, the VA examiner phrased her overall opinion using the correct standard. To the extent of any error in this portion of her discussion, the Board finds that there is no prejudice to the Veteran, as the Board has found separately that the Veteran did not have lesser neck pain that was masked or overshadowed by more back significant pain, and that his assertions on this point are inaccurate. The Veteran's medical records were also noted by the July 2011 VA examiner to be incomplete. She noted that the Veteran was seen for neurosurgical consultation in April 1998; however, there are no further notes from the neurosurgeon, so it is unknown what the neurosurgeon's recommendations were after work-up was complete. She noted that, as the Veteran did not have surgery at the time, which surely would have been recommended for cervical myelopathy from a structural compression of the spinal cord in the cervical spine, the question arises as to whether the neurosurgeon's opinion continued to be that the Veteran had cervical myelopathy, and if so, why was surgery not performed. It was 10 years before the Veteran had cervical surgery which according to Dr. Neumann's letter helped the Veteran's right arm radiculopathy. She also noted that there are no available records from the pre-operative evaluation or from the surgery or follow-up to confirm the Veteran's diagnosis and procedure performed. She opined that the Veteran has symptoms consistent with myelopathy (hyperreflexia with clonus and gait abnormality most prominently); however, no evidence has been provided which ties these symptoms to the Veteran's cervical degenerative disc disease, demonstrating that other causes have been ruled out. According to the examiner, the only available MRI report from 1998 does not reveal cord compression of a severe enough nature to correlate clinically with the Veteran's symptoms and arrive at a diagnosis of cervical myelopathy, and there are no available follow-up records from Veteran's evaluation at that time. Based on the available records and the Veteran's history given to the VA examiner, as well as his concurrent physical examination, it was the VA examiner's opinion that it is less likely than not that the Veteran's remote history of motor vehicle accident caused or contributed to the Veteran's cervical degenerative disc disease. She also found it less likely as not that the Veteran's lumbar spine disability contributed to his cervical spine condition, and that it is less likely as not that the Veteran's cervical spine condition was caused or aggravated by the lumbar microdiscectomy. She noted that there is no plausible mechanism gleaned from the information available and from the examiner's medical knowledge and the medical literature that would connect the lumbar problems to the cervical problems. Furthermore, there is no plausible mechanism for a low back surgery causing or aggravating cervical degenerative disc disease. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App 171 (1991). The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal, 5 Vet. App. at 461; Sklar, 5 Vet. App. 140. The Board finds that the July 2011 VA opinion is the most persuasive medical opinion of record, and that the opinions of Drs. Neumann, Picou, and Rowe are less persuasive. The opinion of Dr. Picou is troubling for its lack of discussion of notable contradictory facts. She first found that there were no cervical complaints at the time of the 1979 motor vehicle accident or for many years after. This, of course, is completely consistent with the Board's finding. She attempted to account for the lack of reporting of symptoms by asserting the possibility of earlier neck symptoms that were not reported due to the severity of symptoms in the lower back. However, perhaps due to the self-acknowledged sparsity of post-service records available for her review, she did not discuss the fact that, even in the presence of back pain, the Veteran was able to report, seek treatment for, and seek service-connected compensation for hearing loss, tinnitus, cysts, warts, benign tumors, sinusitis, a shoulder condition, leg cramps, and hemorrhoids, yet still did not mention neck pain to his treatment providers or to VA, and serious inconsistency in the logic of Dr. Picou's viewpoint. While it is possible that a person may not cite one problem as he or she is being treated for another problem, this Veteran was highly specific and detailed in his reporting, citing such problems as cysts and warts, undermining this assertion that, in this case, Veteran did not cite his neck problems but had neck problems at this time. Indeed, in a March 1997 private treatment report, the Veteran specifically denied posterior neck pain or upper back pain. If Dr. Picou's opinion can account for this factual discrepancy, i.e., that it would be reasonable for the Veteran to report other aches and pains, but to specifically deny neck pain, Dr. Picou did not attempt to explain this clearly factual discrepancy from the Veteran himself. As noted above, the weight of a medical opinion is diminished where that opinion is based on an inaccurate factual premise, or where the basis for the opinion is not stated. See Reonal, 5 Vet. App. at 461; Sklar, 5 Vet. App. 140. Regarding Dr. Neumann's opinion, the discussion is limited entirely to the Veteran's low back disability until the second-to-last sentence, in which Dr. Neumann simply notes a neck surgery in May, 2008, and then states, without explanation, that the etiology of "all these" events is most likely due to slow deterioration and arthritic changes from trauma suffered in the motor vehicle accident of June, 1979. As with Dr. Picou's opinion, there is no discussion or acknowledgment of the specific denial of posterior neck pain in March 1997 or the lack of complaints regarding the neck when examined and treated for back complaints for decades after the injury. As for the opinion of Dr. Rowe, by her own notation, the opinion was based essentially on a review of the opinions of Drs. Picou and Neumann, which she found "quite compelling." Dr. Rowe found it at least as likely as not that the cervical spine disease is post-traumatic in nature. Presumably she was referring to the 1979 injury. This was not explicitly stated; however, she noted that this was consistent with the Veteran's stated history. There is no evidence in the opinion of independent reasoning on the part of Dr. Rowe. The Board presumes that she was truly convinced of the opinion she rendered; however, her lack of explanation and her lack of accounting for notable contradictory facts prevents the Board from sharing her conviction. In sum, the opinions of Drs. Picou, Neumann, and Rowe do not account for significant contradictory evidence. This diminishes the probative weight of these opinions in comparison for a very well-reasoned July 2011 opinion. That opinion accounted not only for the evidence that supported her conclusion, but specifically took into account the conflicting opinions of the Veteran's private doctors. In each instance, she supported her findings with a rationale that is consistent with the record. Moreover, her findings address the questions of direct causation, secondary causation, and aggravation. The Board acknowledges that Dr. Picou and Dr. Neumann had access to certain records; in particular, Dr. Picou stated that she reviewed the Veteran's service treatment records. However, it is what an examiner learns from the record for use in forming the expert opinion-and not just the reading of the record-that matters. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). Here, her opinion does not reflect a complete understanding of the Veteran's post-service symptomatology. The Board has considered the Veteran's assertions regarding etiology. The Veteran described the in-service injury to a July 2011 VA examiner. According to the Veteran, he was involved in a motor vehicle accident in 1979 and spent two days in the hospital. He said his whole body was injured and he was on crutches for three months. The Veteran denied use of a cervical collar, and denied receiving neck treatments. The Veteran reported that his neck ached, but was not intense like the lower back. The Veteran informed the July 2011 VA examiner that he did not complain about the neck pain because his low back was so severe. Similarly, in the VA Form 9, the Veteran wrote that "a man with cancer does not complain about it if he is standing on a rattlesnake." The Board has addressed these contentions to some extent in the discussion of Dr. Picou's opinion: It is certainly reasonable for the Veteran not to have reported mild neck pain immediately following the accident, particularly in light of more significant back pain. However, the accident occurred almost 7 years prior to service separation, and yet the Veteran did not seek treatment during service, despite seeking treatment for among other complaints, left shoulder pain, an ankle injury sustained while playing racquetball, sebaceous cysts, a sore throat, dermatitis, hemorrhoids, and sinus problems (not major problems such as "cancer"). In addition, he did not report neck symptoms at service separation, and as discussed in detail above, he did not mention neck symptoms when he filed a service connection claim after service, despite listing 10 other problems, many of them from lay observation would be consider "mild". Moreover, he specifically denied posterior neck pain to a treatment provider in March 1997. If, as the Veteran now asserts, his back pain was so severe that it somehow precluded him from seeking treatment or even reporting his asserted neck pain, this should logically also have precluded seeking treatment for other lesser problems. The Board finds that the Veteran demonstrated a pattern of seeking treatment for various aches and pains and other conditions during service, and that his assertion that back pain prevented him from seeking treatment for neck pain due to its lesser severity is not an accurate argument. In correspondence received in December 2012, the Veteran reflected on the findings of the July 2011 VA examiner. He agreed that Dr Rowe did not review previous records; however, he asserted that she conducted a clinical evaluation of his present condition and an extensive question and answer session regarding past medical history. The Veteran interpreted her opinion as simply, if what he had told her and what Dr Neumann and Dr. Picou reported were true, then she agreed with them. Regarding the finding of the VA examiner that Dr. Newman's opinion was based on subjective assertions of the Veteran, he believes that Dr. Newman's opinion was based on his military and VA records which he the Veteran provided to him, and on his clinical evaluations over several years. The Board does not question the familiarity of his doctors to his present condition. However none of them has first-hand knowledge of his condition during the entire post-service period, as pointed out by the July 2011 VA examiner, they each based their opinion substantially on the Veteran's account of his symptoms. The Board acknowledges that reliance on a veteran's statements renders a medical opinion incredible only if the Board rejects the statements of the veteran. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005) (citing Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992) for the proposition that Board may not disregard a medical opinion solely on the rationale that the medical opinion was based on a history given by the veteran). The Veterans Court has held that the Board may reject medical opinion based on facts provided by the veteran previously found to be inaccurate. See Reonal, 5 Vet. App. at 460; Swann v. Brown, 5 Vet. App. 229, 233 (1993) (Board is not bound to accept uncorroborated account of medical history but must assess the credibility and weight of the evidence provided by the veteran rejecting it). In this case, the history provided by the Veteran to his private physicians has specifically and explicitly been rejected by the Board for reasons set out in detail above. The Veteran emphasized the opinion of Dr. Picou that an individual might have a lesser pain that is masked or overshadowed by a more significant pain, and the VA examiner's finding that this is simply not sufficient to explain the amount of time between the in-service injury and the first report of symptoms. He asked whether she considered the "copious amount of medication" he was taking during this time. He asserted that, it seems reasonable that the pain medication was doing its job. However, in the December 1986 VA examination conducted to evaluate his multiple claims for disability (which did not include a cervical spine disability), the examiner noted that the Veteran was taking no specific medications for his back, totally undermining the Veteran's contention on this point. Yet, the Veteran did not report neck pain to the examiner, and the examiner diagnosed no disability of the cervical spine. Thus, the record establishes that the Veteran was not taking "copious amounts" of medication during the entire period following service, and his assertion regarding the effect of medication is contradicted by the record. Regarding the VA examiner's notation that the Veteran did not have cervical surgery until 2005 which is nearly 30 years after the in-service injury. He asserted that the back surgery was 20 years after the motor vehicle accident and one year after his first MRI (1997) which indicated the real cause of back pain. The first MRI of the neck was in February 1998 and it revealed conditions similar to the lower back. Both MRIs were virtually the same amount of time after the motor vehicle accident. According to the Veteran, this tends to add credence to the likelihood of the same origin. He asserted that it is obvious that the back and neck condition did not start in 1997 and 1998. The Board finds that the Veteran's assertion misses the essential point: As already discussed, notwithstanding the dates of his surgeries, the Veteran complained of, and was treated for, back pain on a continuing basis after service, and he sought compensation for a back disability just 6 months after service separation; however, he did not complain of neck pain for more than 20 years, and on one occasion, he specifically denied posterior neck pain to a VA examiner, undermining his current contentions. The Veteran noted that the July 2011 VA examiner did not address the plausibility of post traumatic affects which Dr. Rowe, Dr. Picou and Dr. Neumann seem to think was the origin. In fact, the VA examiner did address this assertion and found that an assumption of injury with no complaints at the time of the accident, or for years afterward, and with no objective findings on physical examinations performed in service, point to a lack of cervical injury or condition during service. The examiner also noted that there is no plausible mechanism tying the cervical condition necessitating surgical intervention to the remote history of auto accident without documented neck injury at the time of accident, providing highly probative evidence against the contention that the injury in question caused a neck disability years later. While the Veteran's doctors may genuinely have believed that the cervical spine disability originated from the 1979 accident, they simply did not explain or even address the substantial evidence demonstrating no cervical spine symptoms or treatment for decades after the injury, including some of the Veteran's own prior statements. On the VA Form 9, the Veteran posited that it is not hard to imagine that the trauma which caused the low back problem likely caused the problem at C5-6 which simply took time to manifest itself. As discussed above, the July 2011 VA examiner found this scenario to be unlikely. Moreover, in many respects, this assertion contradicts the Veteran's previous assertion that the cervical spine did manifest itself in the form of neck pain since the injury. This provides further support for the Board's finding that there were no cervical spine symptoms until approximately 1998. The Veteran cannot contend he has had neck pain since service and then contend that it took time to manifest. Finally, the Board notes that the Veteran submitted a December 2011 letter from a friend. His friend noted that he had met the Veteran in the spring of 1994, and had almost daily contact with him until the fall of 2010, when he moved away. The Friend noted that he considers the Veteran to be a good friend and that both were military retirees and had plenty of life experiences to share, and so they spent several hours a day doing so. According to the friend, throughout these many conversations, the Veteran's back condition was often discussed. The friend recalled the Veteran spending a great deal of time lying flat of his back due to pain, and he was often restricted to his house for days. During the time they were neighbors, the Veteran was only able to work for a short time during, the mid 1990's. The friend recalled many times when the Veteran came home from work and was barely able to get out of his car due to his back pain. The friend related that he knew the Veteran had to quit that job because of his back condition. It was not too long after he quit working that the Veteran had back surgery. After his surgery, the Veteran owned a local convenience store with his children and a hired manager, who were responsible for operating and maintaining on a daily basis. During this time, according to friend, the Veteran had two additional surgeries on his shoulders, and later surgery on his neck. The description of the Veteran's friend is competent evidence for the purpose it was submitted, and the Board considers it to be credible. However, other than noting that the Veteran had surgery on his neck, the friend did not describe hearing of or observing any neck symptomatology throughout the post-service period. While the evidence is competent and credible, it does not support the Veteran's assertions regarding the claim. In summation of the Board's findings, the Veteran did not sustain a cervical spine injury or disease in service; symptoms of cervical spine arthritis were not chronic in service and were not continuous since service separation; no current cervical spine disorder is related to service or to any service-connected disability; and no current cervical spine disorder was worsened beyond its natural progress by any service-connected disability. In light of these findings, the Board concludes that service connection for a cervical spine disability is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The Veterans Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this case, the Veteran submitted his claim for service connection in July 2002. He was sent a letter in August 2002 which advised him of basic information and evidence necessary to substantiate a claim of entitlement to service connection. To the extent of any deficiency in detail regarding the Dingess elements or the elements specific to secondary service connection claims, the Board finds that there is no prejudice in this case. Regarding Dingess, as service connection is being denied, no disability ratings or effective dates will result from the Board's decision. Moreover, the Veteran has demonstrated throughout the course of this appeal that he understands the evidence necessary to substantiate his claim on direct and secondary service connection bases. The Veterans Court has held that actual knowledge of the evidence needed to substantiate a claim is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim. Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007). Given the Veteran's specific statements, and those of his attorney, as well as their submission of medical opinion evidence addressing the assertion that his cervical spine disability is related to service, the Board finds that the Veteran has demonstrated actual knowledge of the information and evidence needed to establish the claim. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. It appears that all known and available service treatment reports, and post-service records relevant to the issue on appeal have been obtained and are associated with the Veteran's claims file. The RO has obtained the Veteran's identified VA and non-VA medical records, and SSA records. The information and evidence that has been associated with the claims file also includes the Veteran's written assertions regarding his claim, and those of his attorney. As noted by the July 2011 VA examiner, the post-service period appears to be incomplete regarding treatment records. Nevertheless, the Board finds that the RO made adequate attempts at obtaining the records identified by the Veteran and the record. The Veteran has not identified any outstanding private records that might be obtained. Regarding VA treatment records, VA will make as many requests as are necessary to obtain relevant records from a Federal department or agency. VA will end its efforts to obtain records from a Federal department or agency only if VA concludes that the records sought do not exist or that further efforts to obtain those records would be futile. Cases in which VA may conclude that no further efforts are required include those in which the Federal department or agency advises VA that the requested records do not exist or the custodian does not have them. 38 U.S.C. §5103A(b); 38 C.F.R. § 3.159(c)(1). In July 2012, the RO certified that VA treatment records from January 1991 to December 1993 were unavailable for review and detailed the efforts made to obtain them. The RO notified the Veteran of its findings and he responded in August 2012 that he did not have copies of the records and to the best of his knowledge these visits were to obtain anti-inflammatory medication. In September 2012, the RO certified that VA treatment records from Jacksonville, Florida from January 1987 to December 1988 were unavailable for review and detailed the efforts made to obtain them. The RO notified the Veteran of its findings. He responded in October 2012 that he had no idea where the records were. Based on the RO's certifications, it appears that further attempts to obtain these records would not be fruitful. In addition, the Veteran was afforded a VA examination to address etiology in July 2011. This examination was adequate because it was performed by a medical professional based on a review of claims file, solicitation of history and symptomatology from the Veteran, and a thorough examination of the Veteran. The resulting opinion was accompanied by a thorough rationale, which was consistent with the examination and the record. The Veteran's attorney has asserted that the July 2011 VA examination is inadequate for rating purposes and that remand is required in order to provide the Veteran with an examination and opinion which contains a thorough discussion of all the evidence of record and an adequate rationale. He elaborated that the July 2011 VA examiner improperly dismissed the probative value of the private opinions without adequate supporting rationale. The Board notes that it is not the job of a medical examiner to weigh the probative value of the evidence. It is the task of a medical examiner to provide an opinion and to support that opinion with a rationale based on the record, and with reference to generally accepted medical principles. Moreover, there is no requirement that a medical examiner comment on every favorable piece of evidence in a claims file. Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012); see Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners). The Veterans Court has held that examination reports are adequate when they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion. Monzingo, 26 Vet. App. at 105. In this case, the July 2011 VA examiner supported her opinion with a lengthy and detailed discussion of the pertinent clinical evidence and generally accepted medical principals, as well as addressing the other opinions of record. The suggestion that she should have weighed the probative value of any evidence has no basis in VA law. In this regard, the medical evidence that supports the Veteran provided far less analysis, yet the attorney for the Veteran believed these opinions were "adequate". The attorney also objected to the July 2011 VA examiner's notation that the opinion of Dr. Neumann was based solely on the subjective account of the Veteran versus any objective findings. The attorney asserted that, contrary to the examiner's assumption that Dr. Neumann's letter was based solely on subjective information gleaned from the Veteran, at the time Dr. Neumann had been the Veteran's treating physician for over fifteen years. The July 2011 VA examiner's stated concern regarding the Veteran's assertions being the primary basis for the opinions offered by the private physicians is another way of stating that those opinions do not address significant contradictory evidence in the record. The Board has also found this to be problematic. In fact, the Board has found that the Veteran's history of cervical spine symptoms is not accurate. Thus, there is no deficiency in the finding of the July 2011 VA examiner regarding the private opinions being based on the Veteran's subjective (and inaccurate) account. The fact that Dr. Neumann had treated the Veteran for 15 years prior to 2009 establishes the onset of care in the mid-1990s, roughly coincident with what the Board has found to be the onset of cervical spine symptoms. It is not questioned that the Veteran had ongoing symptoms during this period. It is the symptomatology between service separation and 1997 that is at issue. The Board does not doubt that Dr. Neumann is informed as to the Veteran's condition during the time he has treated the Veteran, nor does there appear to be any doubt on this point expressed by the July 2011 VA examiner. The attorney also asserted that Dr. Neumann's evaluation and opinion were based not only on his intimate personal knowledge of the Veteran's medical history, but also on a review of his military records. As already addressed, the Veterans Court has held that it is not just the reading of the record that matters, it is what an examiner learns from the record for use in forming the expert opinion that matters. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). The failure of Dr. Neumann to address significant contradictory evidence renders his opinion unpersuasive, and therefore, the July 2011 VA examiner's opinion on this regard is not inadequate. The attorney asserted that the July 2011 VA examiner discounted the opinion of Dr. Picou as speculative and lacking in adequate rationale; however, "in her opinion, Dr. Picou provides three pages of rationale, including an extensive review of [the Veteran's] military and medical history." While Dr. Picou acknowledged that she reviewed service records, contrary to the attorney's assertion, Dr. Picou specifically noted that the post-service records were sparse. While she also thought the records were adequate for an opinion, her statement does not indicate an "extensive review." More importantly, the Board has found that her opinion is fundamentally based on an inaccurate factual predicate that the Veteran had continuous cervical spine symptoms since service, which is simply not accurate based on the factual finding of the Board, for reasons stated. The attorney also identified the January 1999 spine examination, at which time the Veteran had already begun complaining of neck pain. It is acknowledged by the Board that the Veteran was complaining of neck pain as early as 1998. It is unclear from the attorney's discussion how this evidence renders the July 2011 VA examiner's opinion inadequate. The attorney argued that the VA examiner did not explain her finding that, in the time intervening service and the onset of neck complaints, biomechanical stresses on the cervical spine were acting on the neck and contributing to the resulting cervical spine pathology. The attorney argued that the examiner failed to articulate the nature or origin of these "biomechanical stresses", what they are, and how they contributed to the development of the Veteran's cervical spine disability. The Board acknowledges that this portion of the opinion appears to be speculative. However, a determination as to the actual cause of the Veteran's cervical spine disability is not what was requested of the VA examiner, and uncertainty on this point does not render the opinion inadequate. VA law does not now require, and has never required, that the actual cause of a claimed disability must be identified and explained in order to deny a claim (the cause of many disabilities may never be known). VA law only requires that a preponderance of the evidence must be against the asserted service-related cause (less than a 50% chance) for the claim to be denied. Here, the examiner was asked whether a cervical spine disability is at least as likely as not related to the in-service motor vehicle accident or whether it is at least as likely as not caused by or aggravated by the Veteran's lumbar spine disability. She rendered unequivocal opinions on these questions. The fact that the examiner could not identify a definite etiology has no bearing on the adequacy of the opinion. The attorney also argued that the Veteran has suffered from a severely antalgic gait resulting from his service-connected lumbar spine disability; however, there is no discussion of the July 2011 examiner as to whether residual effects of his low back disability may have caused or aggravated his cervical spine disability. The Board finds that this assertion is simply inaccurate. The VA examiner's opinion addressed secondary causation and aggravation due to the low back disability and surgery. In sum, the Board finds that the July 2011 VA opinion is adequate and that remand for corrective action is not necessary. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). While substantial compliance is required, strict compliance is not. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999). In this case, the RO substantially complied with the Board's November 2010 remand instructions by requesting from the Social Security Administration all records related to the Veteran's claim for Social Security disability benefits. The also scheduled the Veteran for a VA examination to address the etiology of any disease or injury of his cervical spine. The claims file was provided to the examiner, and the examiner reviewed the claims file in conjunction with the examination. The examiner identified all disorders of the Veteran's cervical spine from which he has suffered since he filed his claim in 2002. The examiner provided a medical opinion as to whether it is as likely as not that any disease or injury of the Veteran's cervical spine had onset during his active service or was caused by his active service. The examiner specifically addressed the 1979 motor vehicle accident. The examiner addressed the April 2009 letter signed by Dr. Neumann and the August 2008 letter signed by Dr. Picou. The examiner provided a medical opinion as to whether it is at least as likely as not that any disease or injury of the Veteran's cervical spine was caused by his service connected chronic low back strain, status post microendoscopic discectomy. The examiner also provided a medical opinion as to whether it is at least as likely as not that any disease or injury of the Veteran's cervical spine was aggravated by the Veteran's service connected chronic low back strain, status post microendoscopic discectomy. The Board notes that the sole reason for the January 2010 Joint Motion was to allow the Board to consider the opinion of Dr. Picou. The Board finds that this has been accomplished. The March 2009 Joint Motion was based on a stipulation of the parties that the Board did not adequately explain its decision that a VA examination was not warranted. The Board also finds that in light of the July 2011 examination and opinion, that deficiency has also been addressed (as an examination was obtained). ORDER Service connection for a cervical spine disability, to include as secondary to a service-connected low back disability, is denied. REMAND In an October 2012 rating decision, the RO granted service connection for radiculopathy affecting the right and left lower extremities and assigned an initial 20 percent rating for each, effective January 18, 2012; granted a TDIU effective January 18, 2012; granted an increased 10 percent rating for hemorrhoids, effective January 18, 2012; granted DEA benefits effective January 18, 2012; denied a disability rating in excess of 40 percent for a low back disability, denied a disability rating in excess of 10 percent for tinnitus; denied a disability rating in excess of 10 percent for a left shoulder disability; and denied compensable disability ratings for bilateral hearing loss and a scar of the right inguinal region. Correspondence received in May 2013 lists as appellate issues: entitlement to a disability rating in excess of 20 percent and effective date earlier than January 18, 2012 for right and left lower extremity radiculopathy, entitlement to an effective date earlier than January 18, 2012 for the assignment of a TDIU, entitlement to a disability rating in excess of 10 percent and effective date earlier than January 18, 2012 for hemorrhoids, entitlement to a rating in excess of 40 percent for a low back disability, entitlement to a disability rating in excess of 10 percent for tinnitus, entitlement to a disability rating in excess of 10 percent for a left shoulder disability, entitlement to a compensable disability rating for bilateral hearing loss, and entitlement to a rating "in excess of 10 percent" for a scar of the right inguinal region. This correspondence includes a request for a statement of the case on the issues so that an appeal can be perfected. A review of the Veterans Appeals Control and Locator System indicates that a notice of disagreement was received at the RO in March 2013. A review of the Virtual VA system reveals that the RO acknowledged the Veteran's disagreement in a July 2013 letter. To date, a statement of the case has not been issued. The Board notes that the attorney accidentally mischaracterized the current rating for the scar of the right inguinal area as 10 percent. The current rating is 0 percent, and has been in place since May 1, 1986. The Board has characterized the issue accordingly. Where a notice of disagreement is filed with respect to certain claims, but a statement of the case has not been issued, the Board must remand the claims to the agency of original jurisdiction (AOJ) to direct that a statement of the case be issued. See 38 C.F.R. §19.9(c)(2012); Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: Issue a statement of the case pertaining to the issues of (1) entitlement to a disability rating in excess of 20 percent for right lower extremity radiculopathy, (2) entitlement to a disability rating in excess of 20 percent for left lower extremity radiculopathy, (3) entitlement to an effective date earlier than January 18, 2012 for the grant of service connection and assignment of a 20 percent initial rating for right lower extremity radiculopathy, (4) entitlement to an effective date earlier than January 18, 2012 for the grant of service connection and assignment of a 20 percent initial rating for left lower extremity radiculopathy, (5) entitlement to an effective date earlier than January 18, 2012 for the assignment of a TDIU, (6) entitlement to a disability rating in excess of 10 percent for hemorrhoids, (7) entitlement to an effective date earlier than January 18, 2012 for the assignment of a 10 percent rating for hemorrhoid, (8) entitlement to a disability rating in excess of 40 percent for a low back disability, (9) entitlement to a disability rating in excess of 10 percent for tinnitus, (10) entitlement to a disability rating in excess of 10 percent for a left shoulder disability, (11) entitlement to a compensable disability rating for bilateral hearing loss, and (12) entitlement to a compensable disability rating for a scar of the right inguinal region. In connection with the above, provide the Veteran with appropriate notice of his appellate rights. The Veteran is reminded that, to vest the Board with jurisdiction over this issue, a timely substantive appeal must be filed after receiving the statement of the case. See 38 C.F.R. § 20.202 (2012). If, and only if, the Veteran perfects the appeal to any issues, the case must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These issues 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). ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs