Citation Nr: 1334825 Decision Date: 10/31/13 Archive Date: 11/06/13 DOCKET NO. 10-39 598 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for failed craniotomy, with skull deformity. 2. Entitlement to service connection for headaches. 3. Entitlement to service connection for benign positional vertigo, claimed as dizziness. 4. Entitlement to service connection for diplopia, claimed as left eye muscle damage. 5. Entitlement to service connection for bone pain. 6. Entitlement to service connection for nerve pain. 7. Entitlement to service connection for scalp scarring. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD D. Johnson, Counsel INTRODUCTION The Veteran served on active duty from January 1965 to November 1968. He also had service in the National Guard, with a period of active duty from March 2003 to March 2004. This matter is before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In February 2013 the Board obtained a medical expert opinion from the Veterans Health Administration (VHA). The Veteran and his representative were provided a copy of the opinion and afforded the opportunity to submit additional evidence and argument, which the Veteran did that same month. In an October 2004 decision, the RO denied the Veteran's claim for head (failed craniotomy) and eye (diplopia) disabilities. Official service department records were subsequently obtained and associated with the claim file. As such, VA must reconsider the Veteran's claim for these disabilities without regard to the finality of the October 2004 RO decision. 38 C.F.R. § 3.156(c) (2013). FINDINGS OF FACT 1. Failed craniotomy with skull deformity, scalp scarring, headaches, diplopia, benign position vertigo, bone pain, and nerve pain did not have onset in and are not otherwise related to the Veteran's first period of service from January 1965 to November 1968. 2. The medical evidence clearly and unmistakably shows that the Veteran's conditions of failed craniotomy with skull deformity, scalp scarring, headaches, diplopia, and benign position vertigo pre-existed service his active duty service from March 2003 to March 2004 and were not aggravated during such service. 3. Symptoms of bone pain and nerve pain are associated with the Veteran's failed craniotomy. 4. Post-operative scalp scarring is a usual effect of surgical treatment for a cerebral aneurysm, performed for ameliorative purposes during military service. CONCLUSIONS OF LAW 1. The criteria for service connection for failed craniotomy, with skull deformity have not been met. 38 U.S.C.A. §§ 1110, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 2. The criteria for service connection for headaches have not been met. 38 U.S.C.A. §§ 1110, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 3. The criteria for service connection for benign positional vertigo have not been met. 38 U.S.C.A. §§ 1110, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 4. The criteria for service connection for diplopia have not been met. 38 U.S.C.A. §§ 1110, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 5. The criteria for service connection for bone pain have not been met. 38 U.S.C.A. §§ 1110, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 6. The criteria for service connection for nerve pain have not been met. 38 U.S.C.A. §§ 1110, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 7. The criteria for service connection for scalp scarring have not been met. 38 U.S.C.A. §§ 1110, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) Upon receipt of a complete or substantially complete application, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. A letter sent in January 2009 satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); 38 C.F.R. § 3.159(b) (1). This letter notified the Veteran of regulations pertinent to the establishment of an effective date and of a disability rating. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was informed of the need to show the impact of disabilities on daily life and occupational functioning. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), rev'd in part sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.); see also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The Veteran's service treatment records from his first period of service, VA and non-VA medical treatment records have been obtained. Medical records obtained in connection with the Veteran's claim for disability benefits from the Social Security Administration have also been associated with the claim file. 38 C.F.R. § 3.159 (c) (2). The Veteran's service treatment records from his second period of service are missing, and all efforts to obtain them have been unsuccessful. A formal finding was issued in April 2009, and the Veteran was notified that his records were missing. Where service records are unavailable, VA has a heightened obligation to assist the Veteran in the development of the claim. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991); Pruitt v. Derwinski, 2 Vet. App. 83, 85 (1992). VA examinations were conducted in July 2009. These opinions are considered inadequate. However, the Board sought an expert medical opinion from the VHA in February 2013. The opinion received in August 2013 is adequate to adjudicate the claim because it is based on claim file review and because the expert considered the Veteran's history and described the disabilities in question, in sufficient detail so that the Board's decision is a fully informed one. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); 38 C.F.R. § 3.159(c)(4). In an August 2013 Informal Hearing Presentation, the Veteran's representative averred that the VHA opinion was inadequate because the expert stated that the Veteran reported hearing "voices" in his head, and because he "let his personal opinion as to the merits of the Veteran's claim interfere with his objectivity." The Board disagrees. First, the expert did not state that the Veteran heard voices in his head. Rather, he stated the Veteran heard "noises" in his head, and then went on to discuss that the Veteran reported hearing noises in his head prior to active duty in March 2003. Second, there is no indication that the expert's opinion was not objective. The opinion was clearly based on the facts presented and the expert's clinical interpretation of those facts based on his expertise as a neurosurgeon. The record does not reflect that the VHA opinion is inadequate for rating purposes for the reasons discussed. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claim file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); see also Dingess/Hartman, 19 Vet. App. at 486. Analysis Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Generally, to establish entitlement to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. All three elements must be proved. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). VA must give due consideration to all pertinent lay and medical evidence in a case where a Veteran is seeking service connection. 38 U.S.C.A. § 1154(a). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may include statements conveying sound medical principles found in medical treatises. 38 C.F.R. § 3.159(a)(1). The Board has an obligation to weigh the probative value of the medical opinions presented based upon factors such as personal examination of the patient, knowledge and skill in analyzing the data, the knowledge and expertise of the examiner, the expressed rationale forming the basis of the opinion, ambivalence and/or exactness of diagnosis, scope of review of the relevant records, bias, etc. See generally, Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). The Board may appropriately favor the opinion of one competent medical authority over another. See Wensch v. Principi, 15 Vet. App. 362, 367 (2001). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b). Service treatment records from the Veteran's first period of service are negative for a brain aneurysm, craniotomy procedure, headaches, benign positional vertigo, diplopia, scalp scarring, and complaints of bone and nerve pain. The Veteran's November 1968 separation examination showed his head, eyes, and neurologic system were all normal. Private medical records, dated prior to the Veteran's second period of military service, reflect that he began to have symptoms which included, but were not limited to, persistent severe and constant left-sided headaches, severe pain over the left eye, left facial numbness, and diplopia beginning in 2000. Complaints of vertigo, dizziness, spinning sensations, and loss of balance were not shown. The Veteran was diagnosed with a left posterior communicating artery (PCA) aneurysm based on his clinical presentation and, underwent a craniotomy (with microvascular dissection and clipping of right PCA aneurysm) in October 2000. He continued to have headaches and diplopia following this surgery. In 2001, two years prior to entering his second period of active duty service, the Veteran began having difficulty with the 2000 procedure due to a contour deformity and sinking of the flap. Diplopia and headaches were present. A January 2001 medical record shows he reportedly felt as though his scalp was 'sinking in.' He also complained of pain in the area of his burr holes and craniotomy defect. Additional notes show that he apparently developed the symptoms of headaches, double vision, and an auditory constellation (characterized by clicking) related to the bone flap sinking in. The private medical records show one complaint of dizziness in January 2001. In January 2001, the Veteran underwent a cranial reconstruction for the persistent contour deformity. Following the cranial reconstruction, his symptoms largely abated, but over the next two years they re-emerged, including a report of occasional dizziness in February 2001. His bone flap is noted to have sunk further over this time as well. Treatment records dated in November 2002 show continued complaints of diplopia, head discomfort, and pain behind his eye and in his ear. On evaluation at a neurofacial surgery clinic in February 2003, the Veteran was observed to have cutaneous scars associated with his prior surgical procedures, and a cranial vault asymmetry with a depression along the left temporoparietal regions. The examining physician's clinical impression was that the cranial bone flap had not healed to the appropriate union and its viability was questionable. It was further thought that his symptoms could be related to the movement of the bone plate and the movement of the acrylic overlay as well. Loose hardware was also present and symptomatic. The physician noted that ultimately reconstruction of that area was likely indicated. The service treatment records associated with the Veteran's second period of active duty service are missing, despite reasonable attempts by the RO to obtain them. The Veteran has submitted copies of service treatment records in his possession; these are in the claim file. The available service records include a March 2003 pre-deployment self-assessment questionnaire. On this questionnaire, the Veteran reported that he was in 'excellent' health and denied having any medical problems; but, he also indicated that he was currently undergoing a medical board. The service records also include a report from a neurologic evaluation conducted at a naval hospital in May 2003. This report shows the Veteran stated he had been in his 'usual state of health' until approximately three weeks prior, at which time he had immediate onset of headache and heard a pop. He noted that since then, he had experienced memory and concentration problems, and diplopia. The report indicates that he was medevaced from Kuwait, started on Neurotonin for the headache, and sent to Florida. A subsequent computed tomography taken in an emergency department revealed a mild dislocation of the cortical bone in the area of his previous surgery, with mild depression below the cortex. The pertinent diagnoses were 1) possible dislocation of previous bone flap, left frontotemporal bone with ++ deformity and mild depression of bone; and 2) diplopia possibly due to dislocation of previous bone flap. Additional records show he was evaluated for surgery and underwent removal of a residual acrylic plate with repeat craniotomy, and split calvarial bone graft for reconstruction of the left temporal region in August 2003, at the Duke University Medical Center. He continued to have headaches and eye pain afterwards. An October 2004 Report of Medical History form, completed in connection with release from active duty, reflects the Veteran's report that his Kevlar and helmet caused a crack in his bone flap while he was in Kuwait. Post-service private medical records reflect complaints of chronic daily headaches, treated with Neurotonin. In an August 2006 treatment note, Dr. Bernier, the Veteran's private family physician, noted that the Veteran previously had chronic headaches secondary to brain surgery that have basically resolved, and no medications were needed in this regard. In July 2009, the Veteran underwent three VA examinations to determine whether his claimed disabilities were either incurred in, or aggravated by, his second period of active duty service from March 2003 to March 2004. Unfortunately, all three VA examination reports are inadequate for adjudication purposes. At the traumatic brain injury examination, a VA examiner reviewed the claim file and opined that the failed craniotomy, double vision, and headaches existed prior to active duty service and were not worsened beyond their natural progression during such service. However, the opinion does not reflect any consideration of the Veteran's contention that his exposure to heat, strenuous physical activity, and wearing of a helmet (which caused weight in the skull area) contributed to his symptoms. At the eye examination, the Veteran was diagnosed with diplopia. The claim file was not reviewed. The eye examiner also failed to indicate whether the Veteran's preexisting diplopia was permanently aggravated (i.e. increased in severity beyond that which would be due to the natural progression of that disease) by the split calvarial bone graft, left parietal to left temporal, which was performed in August 2003, during active duty service. The claim file was also not reviewed during the ear disease examination. The VA examiner provided a diagnosis of benign position vertigo, but did not indicate whether the condition existed prior to service, and if so, whether it had been permanently aggravated by the split calvarial bone graft procedure performed in August 2003. Private medical records reflect complaints of dizziness on two occasions (in January 2001 and in February 2001); however, no specific diagnosis of benign position vertigo is shown. In February 2010, Dr. Bernier, the private family physician, stated the Veteran developed chronic headache, vertigo, and diplopia following his aneurysm recession from the left side of his brain. Dr. Bernier stated that Veteran also has problems with non-healing of his skull area. It was Dr. Bernier's opinion that since the Veteran was still participating in active duty after the surgery, the exposure to heat, strenuous physical activity, and weight in the skull area due to the wearing of a helmet contributed to his chronic symptoms. In February 2013, the Board sought an expert medical opinion from the VHA as to whether the evidence was clear and unmistakable that the Veteran's claimed conditions existed prior to his period of active duty from March 2003 to March 2004, and if so, whether the evidence was clear and unmistakable that these conditions were not aggravated during that period of service. In August 2013, a neurosurgeon reviewed the Veteran's claim file and provided the requested opinions. The expert stated that it is his unwavering assertion that all of the Veteran's claimed conditions clearly and unmistakably existed prior to his period of active duty from March 2003 to March 2004 and it is clear and unmistakable that none of these conditions were or could have been aggravated by anything that happened during this period of service. The expert further explained that the Veteran's signs and symptoms were, and still are, manifestations of the natural history of cerebral aneurysms and their treatment. The expert also addressed all of the Veteran's specific contentions raised in connection with his appeal. The expert noted that while heat and physical exertion can cause a multitude of non-specific signs and symptoms, some of which the Veteran reported, those symptoms existed prior to his period of service and in addition, they are not exclusive to his disease. The expert further noted that it would be physically impossible for the Veteran's helmet to cause his cranioplasty to dislodge because the helmet would not touch or put pressure on the site of his cranioplasty. Finally, with respect to the "pop" that the Veteran reported hearing in Kuwait, the examiner pointed out that it is documented in the Veteran's records that he reported hearing "noises" in his head after his first surgery and before entering active duty service. Failed craniotomy, with skull deformity; Headaches, Benign Positional Vertigo, Diplopia Service treatment records from the Veteran's first period of service are negative for a craniotomy procedure, headache, benign positional vertigo, or diplopia. The Veteran's November 1968 separation examination showed his head, eyes, and neurologic system were all normal. There is no competent evidence showing these conditions manifested in, or are otherwise etiologically related to the Veteran's period of service from January 1965 to November 1968. Consistent with the evidence of record, the Veteran specifically contends that his conditions of failed craniotomy with skull deformity, headaches, diplopia, and benign position vertigo (claimed as dizziness) were either incurred in, or aggravated by his second period of active duty service, from March 2003 to March 2004. Cases in which the preexisting condition is noted upon entry into service, and cases in which the preexistence of the condition must otherwise be established, are to be distinguished. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); Horn v. Shinseki, 25 Vet.App. 231, 234 (2012); see also 38 U.S.C. § 1111 (presumption of sound condition). In a case where there is no preexisting condition noted upon entry into service, the Veteran is presumed to have entered service in sound condition, and the burden falls to the government to demonstrate by clear and unmistakable evidence that the condition preexisted service and was not aggravated by service. Wagner, 370 F3d. at 1345; Horn, 25 Vet.App. at 234; 38 U.S.C. § 1111. The Veteran's service treatment records for his second period of service are missing despite the RO's attempts to locate them. Therefore the claimed conditions of failed craniotomy with skull deformity, headaches, diplopia, and benign position vertigo were not noted upon entry into this period of service and the presumption of soundness applies as to this appeal. VA cannot presume that, at service entry, the Veteran was not sound with respect to any of the residuals of his failed craniotomy. Therefore, if the Board is to find that the presumption of soundness is rebutted and that the Veteran's claimed conditions preexisted his second period of service, it must find that clear and unmistakable evidence shows that these claimed conditions preexisted service; and that clear and unmistakable evidence shows that these conditions were not aggravated by service. Horn, 25 Vet.App. at 234. Consistent with the medical evidence, the August 2013 VHA opinion and the Veteran's statements, the evidence clearly and unmistakably shows that the conditions of failed craniotomy with skull deformity, headaches, diplopia, benign position vertigo pre-existed the Veteran's service from March 2003 to March 2004. In addition, Dr. Bernier's opinion supports a finding that the Veteran's headaches, vertigo, and diplopia existed prior to his period of service that began in March 2003. He unequivocally stated that the Veteran developed these symptoms after his aneurysm recession. There is, however, conflicting evidence as to whether these conditions were aggravated during such service. The Board must weigh the probative value of any available medical opinions, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). The February 2010 medical opinion from Dr. Bernier is significantly less persuasive than the VHA opinion. Dr. Bernier's opinion is not supported by a clinical rationale for the conclusion reached and thus the probative value is lessened. His opinion also does not indicate that any of these conditions were aggravated, specifically during the Veteran's period of active duty from March 2003 to March 2004. Dr. Bernier incorrectly states that the Veteran was "still participating in active duty" after his first craniotomy. The record shows that the Veteran's first craniotomy procedure was performed in October 2000, with reconstruction in January 2001, and it further reflects that the Veteran was not "still participating in active duty" afterwards. Rather, the Veteran did not enter active duty service until several years later, in March 2003. As this medical opinion is based on an inaccurate factual premise, it is not probative. See, Reonal v. Brown, 5 Vet. App. 458, 461 (1993). In contrast, the August 2013 VHA expert has stated, unequivocally, that it is both clear and unmistakable that none of these conditions were or could have been aggravated during the Veteran's period of active duty from March 2003 to March 2004. The opinion is highly persuasive because it is based on the expert's medical experience and expertise as a neurosurgeon and his comprehensive review of the claim file. The opinion was based on an accurate assessment of the pertinent facts and was supported with a clear and well-reasoned clinical rationale. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is no other probative medical opinion that addresses whether the disabilities of failed craniotomy with skull deformity, headaches, diplopia, and benign position vertigo were clearly and unmistakably shown to have preexisted service and to have not been aggravated during such service. The preponderance of the evidence is against the claim of service connection, there is no doubt to be resolved; and service connection for failed craniotomy, with skull deformity; headaches, benign positional vertigo, and diplopia is not warranted. Bone Pain and Nerve Pain The Veteran contends that his symptoms of bone pain and nerve pain were either incurred in, or aggravated by his second period of active duty service, from March 2003 to March 2004. Congress has specifically limited entitlement to service connection to instances where disease or injury has resulted in a disability. See 38 U.S.C.A. §§ 1110, 1131. Without a recognized injury, disease entity or disability, VA is not authorized to award compensation for only reported symptomatology. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a); see also Sanchez -Benitez v. West, 13 Vet. App. 282, 285 (1999); aff'd Sanchez -Benitez v. Principi, 259 F.3d 1356, 1363 (Fed. Cir. 2001). The cumulative medical evidence supports a finding that the Veteran's symptoms of bone and nerve pain are likely related to the residuals of his failed craniotomy with skull deformity. Indeed, the VHA neurosurgeon indicated that all of the Veteran's reported signs and symptoms were, and still are, manifestations of the natural history of cerebral aneurysms and their treatment. The Board has already determined that service connection is not warranted for the treatment of the Veteran's cerebral aneurysm; that is, his failed craniotomy. There is no other diagnosed or identifiable underlying malady or condition that has been associated with the Veteran's symptoms of bone and nerve pain. These symptoms alone do not, in and of themselves, constitute disabilities for which service connection may be granted. The preponderance of the evidence is against the claim of service connection, there is no doubt to be resolved; and service connection for bone pain and nerve pain is not warranted. Scalp Scarring Service treatment records from the Veteran's first period of service are negative for evidence of scars on his scalp. There is no competent evidence showing this condition manifested in, or is otherwise etiologically related to the Veteran's period of service from January 1965 to November 1968. The Veteran contends that his scalp scarring was either incurred in, or aggravated his second period of active duty service, from March 2003 to March 2004. The evidence shows that the Veteran's scalp scarring is attributable to the initial failed craniotomy and reconstruction that he underwent in October 2000 and January 2001, and also as a result of the removal of a residual acrylic plate with repeat craniotomy, and split calvarial bone graft for reconstruction of the left temporal region during service in August 2003 (i.e., the treatment of his cerebral aneurysm). The usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, including postoperative scars, absent or poorly functioning parts or organs, will not be considered service connected, unless the disease or injury is otherwise aggravated by service. 38 C.F.R. § 3.306(b)(1) (2013). The evidence shows that the Veteran's initial failed craniotomy pre-existed his entrance into military service in March 2003 and was not aggravated by service. Therefore, the August 2003 surgery (a repeat craniotomy, and split calvarial bone graft for reconstruction of the left temporal region) is properly viewed, in accordance with 38 C.F.R. § 3.306(b)(1), as remedial or ameliorative treatment for a disorder which clearly pre-existed service. The Board has determined that the preponderance of the evidence is clearly against finding that the Veteran's failed craniotomy was aggravated by service. Therefore, pursuant to 38 C.F.R. § 3.306 (b)(1), service connection for a post-operative scalp scarring as a result of the craniotomy revision during service is, likewise, not warranted. The preponderance of the evidence is against the claim of service connection, there is no doubt to be resolved; and service connection for scalp scarring is not warranted. ORDER Service connection for failed craniotomy, with skull deformity is denied. Service connection for headaches is denied. Service connection for benign positional vertigo, claimed as dizziness, is denied. Service connection for diplopia, claimed as left eye muscle damage, is denied. Service connection for bone pain is denied. Service connection for nerve pain is denied. Service connection for scalp scarring is denied. ____________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs