Citation Nr: 1337311 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 07-36 346 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a cervical spine disability (neck disability). 2. Entitlement to service connection for a lumbar spine disability (back disability). 3. Entitlement to service connection for a left shoulder/arm disability (left upper extremity disability). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Kerry Hubers, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1968 to July 1982. This matter comes before the Board of Veterans' Appeals (Board) from an April 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. On his November 2007 substantive appeal, submitted via VA Form 9, the Veteran requested that he be provided a Board hearing at his local RO. The Veteran was scheduled to have a Travel Board hearing in August 2009 and notice of the hearing was sent to his address of record. However, the Veteran did not appear for the scheduled hearing and did not indicate any desire to reschedule. The Veteran's hearing request is, therefore, deemed withdrawn. 38 C.F.R. § 20.704(d) (2012). In a May 2011 decision, the Board remanded the matter to the RO via the Appeals Management Center (AMC) in Washington, D.C. for additional development to include providing an examination to determine the etiology of any current cervical spine, lumbar spine, and/or left shoulder/arm disability. The requested actions having been completed and the matter readjudicated by the RO in an April 2012 Supplemental Statement of the Case, the matter has properly been returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. The Veteran's cervical spine disability began during or was otherwise caused by his military service. 2. The weight of the evidence is against a finding that the Veteran's lumbar spine disability either began during or was otherwise caused by his military service. 3. The weight of the evidence is against a finding that the Veteran's left shoulder/arm disability either began during or was otherwise caused by his military service. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical spine disability have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). 2. The criteria for service connection for a lumbar spine disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). 3. The criteria for service connection for a left shoulder/arm disability have not been met. 38 U.S.C.A. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Under 38 U.S.C.A. § 7104, Board decisions must be based on the entire record, with consideration of all the evidence. The law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000). The Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). In deciding the Veteran's claim, 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 the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1131; 38 C.F.R. § 3.303. In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Shedden v. Prinicipi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Further, where the veteran asserts entitlement to a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013). For disabilities that are not listed as chronic, under 38 C.F.R. § 3.309(a), the only avenue for service connection is by showing in-service incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). See Walker, 708 F.3d at 1338-39. 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) (2012). 1. Cervical Spine (Neck) Disability The Veteran asserts entitlement to service connection for a cervical spine disability. The Board notes that the Veteran's cervical spine condition has been described, occasionally, as including degenerative joint disease, i.e. arthritis. Arthritis is listed as a chronic disease under 38 C.F.R. § 3.309(a). More recent diagnoses do not include degenerative joint disease and the Veteran's own submissions support that finding. See April 2011 Appellant's Brief ("appellant was diagnosed with cervical spine degenerative disease with spinal stenosis and spinal cord compression status post anterior cervical decompression and fusion"). Neither degenerative disc disease nor spinal stenosis are listed as a chronic disease under 38 C.F.R. § 3.309(a). However, giving the Veteran the benefit of the doubt, the Board will assume for the purposes of analysis that the Veteran's current diagnosis does include arthritis of the cervical spine, a chronic disease under section 3.309(a). Therefore, the Board will apply the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology in analyzing the Veteran's claim for a cervical spine disability. The Veteran has asserted that he originally injured his cervical spine in a motor vehicle accident during service and that he received treatment for that injury while still in service. Service treatment records (STRs) corroborate the Veteran's assertion as they show that he did seek treatment for a stiff neck, sore back, and sore left shoulder/arm in December 1980, three months after the motor vehicle accident. The STRs show that the Veteran complained of numbness and an inability to use his left arm and, although this condition resolved itself, he was prescribed physical therapy. There is no further indication that the Veteran complained of or sought treatment for his injuries or the residuals of those injuries while in service. The Board notes that the Veteran has stated that the reason he did not report continued pain prior to separation was because he wanted to stay in the military. See November 2007 Notice of Disagreement. A March 1982 report on the Veteran's separation examination records the Veteran's complaints regarding continued symptoms: "constant stiff neck more than 18 months; have lost all feeling and movement ability in left arm twice in past 2 years (Auto accident in Aug. 1979)." In December 1985, the Veteran completed an "Applicant Prescreening Form" for the Army Reserves on which he denied arthritis, rheumatism, bursitis, bone, joint or other abnormality, painful or "trick" shoulder, recurrent back pain, or paralysis. The form, as completed by the Veteran, suggests that the Veteran was not experiencing symptoms related to his current cervical spine disability in 1985. The record does not reveal any further treatment of or reports of symptoms related to the Veteran's cervical spine disability until May 2005 when an MRI revealed "degenerative disc disease at multiple levels" with a diagnosis of "[s]pinal and left lateral recess stenosis at C4-5." In November 2005, the Veteran told his treating physician that, since 2004, his neck pain had worsened. At his January 2006 VA examination, he stated that he had been "okay" until 2003. Taken together, these and the other medical records indicate that the Veteran did not experience a chronicity of symptomatology relating to his cervical spine disability since service. The Board finds that the Veteran's symptoms related to his current cervical spine disability abated by 1985 and only reappeared in or around 2003. The Veteran is not entitled to service connection for a cervical spine disability under 38 C.F.R. § 3.303(b). However, the record does support direct service connection under 38 C.F.R. § 3.303(a). The first element of a direct service connection claim is a current disability. That element is not in dispute and has been confirmed by both the January 2006 VA examination and the June 2011 addendum opinion. Shedden, 381 F.3d at 1167. Moreover, the record, particularly the STRs and the Veteran's credible statements, establishes that the Veteran did suffer an injury during service. Id. The remaining element is a causal nexus between the current disability and the in-service event or injury. Id. The VA examiner who provided a report in June 2011 opined that the Veteran's "cervical condition is at least as likely as not (50/50 probability) due to or caused by the cervical condition with radiating left arm pain as seen during military service." The VA examiner went on to explain the basis of his opinion, including that the delayed onset of initial symptoms, subsequent improvement of symptoms, and then later reoccurrence of symptoms is "quite common" for whiplash injuries of the type experienced by the Veteran in service. The Board finds the VA examiner's opinion to be thorough, well-reasoned, and persuasive. There are no negative etiological opinions of record with respect to the cervical spine disability claim. Therefore, the Board finds that the evidence is at least in equipoise on the issue of a causal nexus between the Veteran's current cervical spine disability and the in-service injury of his cervical spine. Because the evidence is at least in equipoise, the Veteran prevails on service connection for a cervical spine disability. Gilbert, 1 Vet. App. at 53-56. Entitlement to service connection for a cervical spine disability is granted. 2. Lumbar Spine (Back) Disability The Veteran also asserts entitlement to service connection for a lumbar spine disability. The Veteran's current lumbar spine disability has been diagnosed as degenerative disc disease and degenerative joint disease, i.e. arthritis. Arthritis is listed as a chronic disease under 38 C.F.R. § 3.309(a), therefore the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology apply to the Veteran's claim for a lumbar spine disability. The Veteran has asserted that he originally injured his lumbar spine in a motor vehicle accident during service and that he received treatment for that injury while still in service. Service treatment records (STRs) document that the Veteran did seek treatment for a stiff neck, sore back, and sore left shoulder/arm in December 1980, three months after the motor vehicle accident. The STRs show that the Veteran complained of numbness and an inability to use his left arm. Examination of his back showed that he had full range of motion at that time. There were no diagnoses of disc or other injuries to his back and he received no treatment directed to his lumbar spine at that time. There is no further indication that the Veteran subsequently complained of or sought treatment for lower back pain while in the service. As noted above, the Board notes that the Veteran has stated that the reason he did not report continued pain prior to separation in 1982 was because he wanted to stay in the military. See November 2007 Notice of Disagreement. A March 1982 report on the Veteran's separation examination records the Veteran's complaints regarding continued symptoms: "constant stiff neck more than 18 months; have lost all feeling and movement ability in left arm twice in past 2 years (Auto accident in Aug. 1979)." The symptoms reported by the Veteran at that time do not include back pain. Moreover, in December 1985, the Veteran completed an "Applicant Prescreening Form" for the Army Reserves on which he denied arthritis, rheumatism, bursitis, bone, joint or other abnormality, painful or "trick" shoulder, recurrent back pain, or paralysis. The form, as completed by the Veteran, suggests that the Veteran was not experiencing symptoms related to his current lumbar spine disability in 1985. The record does not reveal any further treatment or reports of symptoms related to the Veteran's lumbar spine disability until early 2005 when he reported having back pain. In May 2005, an MRI revealed degenerative problems in the Veteran's cervical spine. The Veteran reported at that time that the pain from his cervical spine radiated down to his lumbar area. In November 2005, the Veteran told his treating physician that he had some low back pain. The Veteran was diagnosed with "myelopathy secondary to a herniated disc and spur C4-C5", but not with any lumbar spine issues. At his January 2006 VA examination, he indicated that his lower back pain was coincident with his cervical spine (neck) pain. X-rays in conjunction with the January 2006 VA examination indicated that the Veteran had lumbar spondylosis and the examiner diagnosed the Veteran with lumbar spine degenerative disc and joint disease "with normal exam today". Taken together, these and the other medical records indicate that the Veteran did not experience a chronicity of symptomatology since service with respect to his lumbar spine disability. The evidence indicates, and the Board finds, that any lumbar spine pain the Veteran experienced shortly after the in-service automobile accident resolved prior to his separation from the service in 1982 and did not return until over twenty years later. Therefore, the Veteran is not entitled to service connection for a lumbar spine disability under 38 C.F.R. § 3.303(b). The only other avenue for service connection is by showing in-service incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). See Walker, 708 F.3d at 1338-39. 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) (2012). As previously noted, in order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Shedden, 381 F.3d at 1167. The evidence, including the January 2006 VA examination, establishes that the Veteran does have a current lumbar spine disability, to include degenerative disc and joint disease. The evidence also shows that the Veteran did experience an in-service event or injury, namely the motor vehicle accident. Thus, the only remaining element with respect to this claim is a causal nexus between the in-service injury or disease and the current lumbar spine disability. Id. The Board may not render its own medical judgment in determining what role, if any, an in-service injury played in the development of the Veteran's current lumbar spine disability. See, e.g., Colvin v. Derwinski, 1 Vet. App 171, 175 (1991). Therefore, the Board will review the medical evidence of record on this issue, including the VA examiner's opinion and the Veteran's own statements regarding his medical history and condition. The Board remanded this matter in May 2011 to obtain an etiological opinion from a VA examiner. The VA examiner who provided the requested opinion thoroughly reviewed the claims file, the Veteran's service treatment and medical records, and the notes of the VA physician who examined the Veteran in January 2006. In her June 2011 report, the VA examiner discussed the Veteran's relevant medical history and concluded that the Veteran's lumbar spine disability, to include degenerative disc disease and degenerative joint disease, was not due to or caused by the sore back or any injury during the Veteran's military service. The VA examiner reasoned that the whiplash injury that the Veteran reported shortly after the in-service accident and the lack of a serious motor vehicle accident requiring immediate care were "extremely unlikely to cause any lumbar damage." The VA examiner also noted the lengthy, asymptomatic period between the December 1980 report of back pain and the next complaints of back pain in 2005. Based on a thorough review of the available medical evidence, the VA examiner provided a well-reasoned and persuasive opinion regarding the causal nexus, or lack thereof, between the Veteran's military service and his current lumbar spine disability. The Board recognizes that the Veteran believes that his current lumbar spine disability is related to his active service. While the Veteran is competent to report (1) symptoms observable to a layperson (i.e. low back pain); (2) a diagnosis that is later confirmed by clinical findings; or (3) a contemporary diagnosis, the Board need not find a lay Veteran competent to render opinions regarding etiology of a medically diagnosed condition nor need the Board give any probative weight to bald assertions by a lay Veteran regarding that subject. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); King v. Shinseki, 700 F.3d 1339, 1344-45 (Fed. Cir. 2012). This Veteran, who lacks medical training, is not competent to opine on the etiology of his current lumbar spine disability, a condition that was first diagnosed, over 20 years after the alleged in-service injury, by a medical professional based on the results of diagnostic testing. See, e.g., Jandreau, 492 F.3d at 1377. Thus, the Board concludes that the only probative evidence of record regarding the etiology of the Veteran's current lumbar spine disability is the well-supported and well-reasoned June 2011 opinion of the VA examiner. Accordingly, the Board concludes that the evidence is not in equipoise on the claim of entitlement to service connection for a lumbar spine disability and the benefit of the doubt rule does not apply. See 38 U.S.C.A. § 5107 (West 2002). The Veteran's claim of entitlement to service connection for a lumbar spine disability is denied. 3. Left Shoulder/Arm Disability Lastly, the Veteran asserts entitlement to service connection for a left shoulder/arm disability. The Veteran has been diagnosed with arthritis in his left shoulder/arm. See March 2003 Report on MRI of Left Shoulder (indicating degenerative arthritis of the acromioclavicular joint with impingement of the supraspinatus tendon). Arthritis is listed as a chronic disease under 38 C.F.R. § 3.309(a), therefore the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology apply to the Veteran's claim for a left shoulder/arm disability. The Veteran has asserted that he originally injured his left shoulder and arm in a motor vehicle accident during service and that he received treatment for that injury while still in service. Service treatment records (STRs) document that the Veteran did seek treatment for a stiff neck, sore back, and sore left shoulder/arm in December 1980, three months after the motor vehicle accident. The STRs show that the Veteran complained of numbness and an inability to use his left arm. The Veteran was prescribed physical therapy, but did not attend. The symptoms appear to have resolved. There is no further indication that the Veteran sought treatment for left shoulder/arm pain while in service. As noted above, the Board notes that the Veteran has stated that the reason he did not report continued pain prior to separation in 1982 was because he wanted to stay in the military. See November 2007 Notice of Disagreement. A March 1982 report on the Veteran's separation examination notes the Veteran's complaints regarding continued symptoms: "constant stiff neck more than 18 months; have lost all feeling and movement ability in left arm twice in past 2 years (Auto accident in Aug. 1979)." In December 1985, the Veteran completed an "Applicant Prescreening Form" for the Army Reserves on which he denied arthritis, rheumatism, bursitis, bone, joint or other abnormality, painful or "trick" shoulder, recurrent back pain, or paralysis. The form, as completed by the Veteran, suggests that the Veteran was not experiencing symptoms related to his current left shoulder/arm disability in 1985. The record does not reveal any further treatment of or reports of symptoms related to the Veteran's left shoulder/arm disability until March 2003 when an MRI revealed degenerative arthritis of the acromioclavicular joint with impingement of the supraspinatus tendon. The Veteran underwent a decompression surgery in May 2003 which temporarily relieved his symptoms. Taken together, these and the other medical records indicate that the Veteran did not experience a chronicity of symptomatology since service with respect to his left shoulder/arm disability. The evidence indicates, and the Board finds, that any left shoulder/arm pain the Veteran experienced shortly after the in-service automobile accident resolved prior to or shortly after his separation from the service in 1982 and did not return until over twenty years later. Therefore, the Veteran is not entitled to service connection for a lumbar spine disability under 38 C.F.R. § 3.303(b). As noted above, the only other avenue for service connection is by showing in-service incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). See Walker, 708 F.3d at 1338-39. 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) (2012). As previously noted, in order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Shedden, 381 F.3d at 1167. The evidence, including the January 2006 VA examination, establishes that the Veteran does have a current left shoulder/arm disability. The most recent diagnosis of the Veteran's current left shoulder/arm disability is: left shoulder impingement syndrome resolved status post decompression surgery with residual limitation of motion and arthritis. The evidence also shows that the Veteran did experience an in-service event or injury, namely the motor vehicle accident. Thus, the only remaining element with respect to this claim is a causal nexus between the in-service injury or disease and the current left shoulder/arm disability. Id. The Board may not render its own medical judgment in determining what role, if any, an in-service injury played in the development of the Veteran's current left shoulder/arm disability. See, e.g., Colvin, 1 Vet. App at 175. Therefore, the Board will review the medical evidence of record on this issue, including the VA examiner's opinion and the Veteran's own statements regarding his medical history and condition. The Board remanded this matter in May 2011 to obtain an etiological opinion from a VA examiner. The VA examiner thoroughly reviewed the claims file, the Veteran's service treatment and medical records, and the notes of the VA physician who examined the Veteran in January 2006. In her June 2011 report, the VA examiner discussed the Veteran's relevant medical history and concluded that it is less likely as not, less than 50/50 probability, that the Veteran's left shoulder/arm disability, to include impingement syndrome and residuals of decompression surgery, is due to or caused by the shoulder soreness or the motor vehicle accident while in service. The VA examiner reasoned that the whiplash injury that the Veteran reported shortly after the in-service accident can cause radiating pain to the shoulder, but the fact that the Veteran did not seek care immediately after the accident suggests that the accident did not cause a significant shoulder injury. The VA examiner also noted the "long time frame of asymptomatic left shoulder" which, the examiner concluded, suggested that the impingement syndrome for which the Veteran sought treatment in 2003 was a separate condition and not due to the accident nor was it developed during military service. Based on a thorough review of the available medical evidence, the VA examiner provided a well-reasoned and persuasive opinion regarding the lack of a causal nexus between the Veteran's military service and his current left shoulder/arm disability. As above, the Board recognizes that the Veteran believes that his current left shoulder/arm disability is related to his active service. The Board again notes that, though the Veteran is competent to report things he can observe, such as symptoms like pain or a contemporary diagnosis, the Board need not find a lay Veteran competent to render opinions regarding the etiology of a diagnosed condition nor need the Board give any probative weight to bald assertions by a lay Veteran regarding that subject. Davidson, 581 F.3d at 1316; King, 700 F.3d at 1344-45. This Veteran, who lacks medical training, is not competent to opine on the etiology of his current left shoulder/arm disability, a condition that was first diagnosed by a medical professional based on the results of diagnostic testing. See, e.g., Jandreau, 492 F.3d at 1377. Thus, the Board concludes that the only probative evidence of record regarding the etiology of the Veteran's current left shoulder/arm disability is the well-supported and well-reasoned June 2011 opinion of the VA examiner. Accordingly, the Board concludes that the evidence is not in equipoise on the claim of entitlement to service connection for a left shoulder/arm disability and the benefit of the doubt rule does not apply. See 38 U.S.C.A. § 5107 (West 2002). The Veteran's claim of entitlement to service connection for a left shoulder/arm disability is denied. Duties to Notify and Assist When VA receives a complete or substantially complete application for benefits, it 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. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In the instant case, notice was provided to the Veteran in October 2005 and again in March 2006 prior to the initial adjudication of his claims in April 2006. The contents of the notice letters fully comply with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. The Veteran was notified of the evidence not of record that was necessary to substantiate the claim, and was told that he needed to provide the names of the persons, agency, or company who had additional records to help decide his claim. He was also informed that VA would attempt to determine what additional information was needed to process his claim, and that VA would schedule a VA examination if appropriate, obtain VA medical records, obtain service records, and obtain private treatment reports as indicated. As the contents of the notice letters fully comply with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), the Board concludes that VA satisfied its duties to notify the Veteran. VA must also make reasonable efforts to assist the appellant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claims. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2012). VA's duty to assist includes assisting the claimant in the procurement of service and other relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO associated the Veteran's service treatment records and VA treatment records with the claims file. The Veteran has not identified any treatment records aside from those that are already of record. Thus, the Board concludes that VA has made every reasonable effort to obtain all records relevant to the Veteran's claim. VA also satisfied its duty to obtain a medical examination. In January 2006, VA provided the Veteran a medical examination. Subsequent to the May 2011 remand by the Board, the VA sought and obtained an addendum to the report on the prior examination regarding the etiology of any current cervical spine, lumbar spine, and/or left shoulder/arm disability is related to the Veteran's active service. The examination and subsequent reports are adequate as the VA examiners reviewed the Veteran's pertinent medical history, conducted a clinical evaluation of the Veteran, and provided an adequate discussion of relevant symptomatology and possible etiology of the Veteran's cervical spine, lumbar spine, and left shoulder/arm disabilities. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007); Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). Therefore, VA has no obligation to obtain further medical examinations or opinions in connection with the claims based on those disabilities. See 38 U.S.C.A. § 5103(A)(d); see also Wells v. Principi, 326 F.3d 1381, 1384 (Fed. Cir. 2003). In light of the foregoing, the Board is satisfied that all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to the issue on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103 and 5103A; 38 C.F.R. § 3.159. ORDER Entitlement to service connection for a cervical spine disability (neck disability) is granted. Entitlement to service connection for a lumbar spine disability (back disability) is denied. Entitlement to service connection for a left shoulder/arm disability (left up extremity disability) is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs