Citation Nr: 1608474 Decision Date: 03/02/16 Archive Date: 03/09/16 DOCKET NO. 14-00 054 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased rating for degenerative disc disease, lumbar spine, currently rated as 10 percent disabling. 2. Entitlement to an increased rating for degenerative disc disease, cervical spine, currently rated as 10 percent disabling. 3. Entitlement to service connection for hypertension, to include as secondary to service-connected disabilities. 4. Entitlement to service connection for left carpal tunnel syndrome, to include as secondary to service-connected disabilities. 5. Entitlement to service connection for obstructive sleep apnea. REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs ATTORNEY FOR THE BOARD A. Adamson, Counsel INTRODUCTION The Veteran served on active duty from March 1981 to July 2001. This case is before the Board of Veterans' Appeals (Board) on appeal of an August 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. When this case was before the Board in June 2015, it was decided in part and remanded in part for additional development. The matters remaining on appeal are now again before the Board for further appellate action. The record before the Board consists of the Veteran's electronic records within Virtual VA and the Veterans Benefits Management System (VBMS). The issues of entitlement to an increased rating for cervical spine disability and entitlement to service connection for hypertension and left carpel tunnel syndrome are addressed in the REMAND that follows the ORDER section of this decision. FINDINGS OF FACT 1. Throughout the pendency of this claim, the Veteran's lumbar spine degenerative disc disease has been manifested by limitation of motion, but forward flexion of the thoracolumbar spine has been greater than 60 degrees, the combined range of motion of the thoracolumbar spine has been greater than 120 degrees, and neither incapacitating episodes of intervertebral disc disease, nor muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis has been present. 2. Obstructive sleep apnea has not been present during the period of the claim. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for degenerative disc disease, lumbar spine, are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.71a, Diagnostic Code 5242 (2015). 2. The criteria for service connection for obstructive sleep apnea are not met. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2014), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2015), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) (West 2014), requires that notice to a claimant pursuant to the VCAA be provided 'at the time' that or 'immediately after' VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The timing requirement enunciated in Pelegrini applies equally to the initial-disability-rating and effective-date elements of a service-connection claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). With respect to the issues decided herein, the record reflects that the Veteran was provided all required notice in the letter mailed in January 2010, prior to the issuance of the August 2010 rating decision on appeal. All appropriate development to obtain the Veteran's service treatment records (STRs) and post-service VA and private medical records has been completed. Moreover, the Veteran has been afforded appropriate VA examinations in response to his claim for an increased rating for the service-connected lumbar spine disability and with regard to service connection for sleep apnea, most recently in August 2015. The Veteran has not asserted, and the evidence of record does not show, that the low back disability has increased significantly in severity since the most recent examination. The Veteran has not identified any pertinent, outstanding records that could be obtained to substantiate his claims. The Board is also unaware of any such records. Accordingly, the Board concludes that VA has complied with its duty to assist the Veteran. The Board will now address the merits of these claims. II. Burdon of Proof Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. 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 claimant. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2015); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. III. Disability Rating Legal Criteria Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2015). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321(a), 4.1 (2015). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2015). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2015). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2015). 38 C.F.R. § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Veteran's degenerative disc disease of the lumbar spine is rated under the general rating formula for rating diseases and injuries of the spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5242 (2015). Intervertebral disc syndrome (IVDS) is evaluated under the general formula for rating diseases and injuries of the spine or under the formula for rating IVDS based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2015). In this case, however, there is no indication in the record that the Veteran's lumbar spine disability is manifested by incapacitating episodes; thus, the formula for rating IVDS based on incapacitating episodes is not applicable in this case. Under the general rating formula for rating diseases and injuries of the spine, with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings apply. An evaluation of 10 percent is warranted if forward flexion of the thoracolumbar spine is greater than 60 degrees, but not greater than 85 degrees; the combined range of motion of the thoracolumbar spine is greater than 120 degrees, but not greater than 235 degrees; there is muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or there is vertebral body fracture with loss of 50 percent or more of the height. An evaluation of 20 percent is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees, but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted if forward flexion of the thoracolumbar spine is to 30 degrees or less or if there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent evaluation is warranted if there is unfavorable ankylosis of the entire spine. In determining the degree of limitation of motion, the provisions of 38 C.F.R. § 4.40 (2015) concerning lack of normal endurance, functional loss due to pain, and pain on use and during flare-ups; the provisions of 38 C.F.R. § 4.45 (2015) concerning weakened movement, excess fatigability, and incoordination; and the provisions of 38 C.F.R. § 4.10 (2015) concerning the effects of the disability on the veteran's ordinary activity are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). There are several notes set out after the diagnostic criteria, which provide the following: First, associated objective neurologic abnormalities are to be rated separately under an appropriate diagnostic code. Second, for purposes of VA compensation, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is to 240 degrees. Third, in exceptional cases, an examiner may state that, because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in the regulation. Fourth, each range of motion should be rounded to the nearest 5 degrees. Fifth, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Sixth, disabilities of the thoracolumbar and cervical spine segments shall be separately evaluated, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243. Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2015) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disability. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disability under review. In this regard the Board notes that where entitlement to compensation has already been established and an increase in the disability is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Veteran was awarded service connection for lumbar spine degenerative disc disease by way of a July 2001 rating decision. A 10 percent rating was assigned. He filed this claim for an increased rating in January 2010. The Veteran underwent a VA examination in May 2010. The Veteran reported pain, stiffness, weakness, fatigability, lack of endurance and incapacitation at this time. He reported a feeling of a constant knot in his back, along with tingling and numbness going from the back of his left leg to his heel. He reported no bladder or bowel complaints. He reported flare-ups of pain to the level of a six on a scale of one to ten, occurring one to two times per week, lasting from 30 minutes to a half a day. The Veteran confirmed at the time of this examination that he had no periods of treatment for his back disability in the prior year, no physical therapy, no injections and no brace. He managed his symptoms with pain medication, heat, and lying flat with his legs up. Physical examination revealed a normal gait with no thoracic kyphosis or lumbar lordosis. The examiner observed decreased strength in the left calf, but attributed it to a history of left Achilles rupture. The Veteran's lower extremities were normal to pinprick and light touch and vibration. Forward flexion was 0 to 75 degrees; extension 0 to 25 degrees, with pain; right and left lateral flexion 0 to 25 degrees; left lateral rotation 0 to 20 degrees; and right lateral rotation 0 to 30 degrees. Other than the pain noted with extension, the examiner reported no additional painful motion, tenderness, spasm, effusion, edema, fatigability, lack of endurance, weakness, incoordination, laxity or instability. There was no additional loss of function with repetition. June 2014 primary care clinical notes show ongoing indication of limitation of motion, although specific degrees were not noted, as well as tenderness on palpation, but a normal appearance with no spasms. Sensory examination of the lower extremities was conducted and was noted as normal. Strength of the lower extremities was also normal. The Veteran most recently underwent a VA examination in August 2015. This VA examiner again confirmed the existence of degenerative disc disease, based upon 2001 radiological findings. At the time of this examination, the Veteran reported no flare up of thoracolumbar spine symptoms, and no functional loss or impairment. The examiner reported that the range of motion, when initially measured, was all normal and without pain. The examiner confirmed the absence of ankylosis in the spine. The examiner also indicated there was no pain on palpation. The Veteran did not experience additional loss of function or range of motion after repetitive testing. The Veteran also did not report pain, weakness, fatigability, or incoordination with repetitive use. The examiner did not observe guarding or muscle spasm and muscle strength testing and sensory testing were normal. The Veteran did not report radicular symptoms at the time of this examination, or any other neurologic abnormalities. The examiner also stated the Veteran does not have IVDS, or any other pertinent physical findings. There is no additional evidence showing range of motion or other symptoms related to the Veteran's lumbar spine disability at any time during the period of this appeal. Again, the Veteran reported to the 2010 VA examiner that he was not receiving clinical treatment for his back. In sum, the record does not contain evidence showing that the Veteran's forward flexion of the thoracolumbar spine has been limited to 60 degrees or less; combined range of motion not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The Veteran's reports of pain are considered, but there is no evidence of further limitation of motion or other functional impairment due to that pain. There is simply no basis under the schedular criteria for a rating in excess of 10 percent for the Veteran's lumbar spine disability. Moreover, there are no neurologic abnormalities for which separate ratings could be granted. The Veteran reported radiating symptoms at the time of his 2010 VA examination;, however, neurological examination of the lower extremities have disclosed no abnormality for which a separate rating can be granted. The Board has considered the rating criteria pertaining to arthritis, to IVDS, and to related neurological disorders. The record does not show that any of these manifestations exists. The Veteran's appeal as to this issue must be denied. Additional Considerations VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). The Board has accordingly considered the lay evidence offered by the Veteran, in the form of correspondence to VA, in addition to the medical evidence cited above. The Veteran is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). However, even affording the Veteran full competence and credibility, the preponderance of the evidence establishes that he is not entitlement to a higher rating under any applicable diagnostic code for the disability rating determined above. Consideration has been given to assigning a staged rating for the disability decided herein; however, at no time during the period in question has the disability warranted more than the assigned rating, so staged ratings are not appropriate for this claim. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered whether the case should be referred to the Director of the Compensation Service for extra-schedular consideration. In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the claimant's disabilities with the established criteria provided in the rating schedule for each disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the manifestations of the service-connected disability at issue, as discussed above, are contemplated by the schedular criteria. There is no contention by the Veteran or indication in the record that the average industrial impairment from the disability would be in excess of that contemplated by the assigned rating. The Board has therefore determined that referral of this case for extra-schedular consideration under 38 C.F.R. § 3.321(b) is not in order. IV. Service Connection Legal Criteria Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). "Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability ... in the absence of a proof of present disability there can be no claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Court has held that the requirement for service connection that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim even though the disability resolves prior to the Secretary's adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Analysis In this case, the Board has reviewed all of the evidence of record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim at issue. The Veteran contends he has obstructive sleep apnea and he alleges it is causally connected to his active service. The record includes a March 2001 VA examination report noting a prior history of sleep apnea, which was deemed resolved following uvulopalatopharyngoplasty. The examiner found no evidence of existing sleep apnea at this time, which was shortly prior to the Veteran's separation from active service. The Veteran filed this claim for service connection in 2010. In May 2010, he underwent a VA examination. The examiner observed the in-service treatment, which included a tonsillectomy for obstructive sleep apnea, although no sleep study was performed in service. The notation of sleep apnea in the service treatment records is based upon reports of snoring and witnessed cessation of breathing. At the time of the VA examination in 2010, he reported daytime hypersomnolence and falling asleep in the afternoon. At that time he was not using a CPAP machine. The examiner then listed the results of a May 2010 sleep study, a copy of which was also submitted by the Veteran in July 2010. This report includes apnea-hypopnea index within normal limits at 1.8 per hour, which were 0 obstructive, 10 hypopneic, 0 central and 0 mixed. Baseline saturation was 97 percent and the lowest oxygen saturation during the study was 92 percent. This was deemed a normal sleep study, and the examiner found there to be no objective evidence of sleep apnea. In concluding, the examiner again pointed out that the in-service diagnosis of sleep apnea was based only on the Veteran's history of snoring with witnessed sleep interruption, but not based upon a sleep study. In July 2010, the Veteran underwent a private titration study. The report indicates this study was based upon a referral for a nasal CPAP/BIPAP titration study due to a previous suggestion of sleep apnea. The report references the findings in the May 2010 report. The Veteran wore a CPAP device during testing. The impressions were "REM related sleep apnea by previous study" with good control of obstructive events with CPAP, as well as a note of significant hypersomnolence. Thus, this report does not include an indication of obstructive sleep apnea. It merely refers to the symptoms noted in previous reports, which, as discussed above, do not establish a diagnosis of sleep apnea. Because of the suggestion, however, the Board remanded this issue in June 2015 for another VA examination to determine whether the Veteran has obstructive sleep apnea. In April 2015, the Veteran submitted a statement summarizing his in-service experiences including being woken up because of his snoring and trouble sleeping. He also recalled his wife waking him and reporting his snoring and trouble sleeping. His wife also submitted a statement recalling these symptoms. In August 2015, the Veteran again underwent VA examination. The examiner again reviewed the findings of the May 2010 sleep study and concluded that the result of the study found the diagnosis as primary snoring, not obstructive sleep apnea. The examiner concluded that there is insufficient evidence to warrant or confirm a diagnosis of either an acute or chronic obstructive sleep apnea condition or its residuals. While the Board recognizes the Veteran's symptoms of snoring and his use of a CPAP machine during the pendency of this claim, there is no competent medical evidence of a diagnosis of obstructive sleep apnea during the period of the claim. The Board has also considered the Veteran's own statements and his belief that he has obstructive sleep apnea. While the Veteran might sincerely believe that to be the case, as a layperson, he is not competent to provide an opinion concerning this matter requiring medical expertise. As the Veteran has not shown a current disability for which service connection can be granted, the claim for service connection for obstructive sleep apnea must be denied. The Board has duly considered the benefit of the doubt doctrine. 38 U.S.C.A. § 5107; see also Gilbert. However, the preponderance of the evidence is against the Veteran's claim, so that doctrine is not applicable to this claim. Service connection for obstructive sleep apnea must be denied. ORDER A rating in excess of 10 percent for chronic degenerative disc disease of the lumbar spine is denied. Service connection for obstructive sleep apnea is denied. REMAND The remaining issues on appeal require additional evidentiary development. For the reasons described below, the Board finds that the originating agency failed to substantially comply with the June 2015 Board remand directives. Such noncompliance is error on the part of the originating agency. Moreover, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the Board must once again remand these issues for compliance. Cervical Spine Rating On VA examination in May 2010, the Veteran reported severe pain going down his left arm, with numbness and tingling in both arms. The pain begins at the base of the neck in the midline and radiates to the left side of his back and chest, and mainly to the left arm to the fingertips causing tingling, burning and numbness. Physical examination revealed normal sensation to pinprick and light touch and vibration of the upper extremities. The examiner confirmed the degenerative disc disease diagnosis, but made no mention as to whether there was any diagnosis appropriate for the Veteran's radiating symptoms. In August 2010, the VA examiner provided an addendum report, citing a February 2009 cervical MRI and a March 2009 EMG, neither of which included indication of left cervical radiculopathy. The examiner concluded that the Veteran's decreased sensation and decreased strength testing noted in the July 2010 VA examination report, "is solely & entirely due to left carpel tunnel syndrome." Records related to the Veteran's cervical spine in 2010 and 2011 show treatment with a neurosurgeon for neck pain, with symptoms radiating into his upper extremities, particularly on the left. In March 2011, the Veteran underwent surgery for cervical spine stenosis, including cervical discectomy, osteophytectomies and foraminotomies to decompress the spinal cord and nerve roots, as well as other procedures related to herniation of discs in the cervical spine. The narrative portion of the operative report describes the Veteran's report of an in-service rough parachute landing resulting in chronic neck pain and left upper extremity pain, paresthesias and weakness, which progressively worsened over the prior thirteen years. The Veteran described pain radiating from his neck into his left shoulder and arm, as well as numbness and tingling involving the left thumb, left index finger, and occasionally into the left middle finger, as well as decreased left hand grip. In June 2015, the Board remanded the matter of whether an increased rating is warranted for the Veteran's degenerative disc disease of the cervical spine. The originating agency was to afford the Veteran an examination to determine the current severity of his cervical spine disability, which was to include an assessment of range of motion, functional loss, incapacitating episodes, and neurologic abnormalities. The Veteran underwent a VA examination in August 2015. The examiner reported functional loss as including constant pain radiating to the left arm. Later in the report, however, the examiner indicated the Veteran does not have radicular pain or other signs or symptoms of radiculopathy, and no other neurologic abnormalities. The examiner went on to conclude, recognizing the Veteran's diagnosis as including cervical spondylosis of C5-7, but finding that the condition is not the same as the service-connected degenerative disc disease, is not a progression of the service-connected disability and was not caused by the service-connected disability. The examiner made no mention of the extensive treatment and surgery in 2010 and 2011, which included a description of pain radiating from the neck into the upper extremity. Given the examiner's conclusion, which included little reasoning and no reference to the Veteran's detailed medical history, the Board finds his report of little probative value. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). To date, the Veteran has not been afforded an examination with a comprehensive analysis of his cervical spine symptoms, particularly his symptoms suggestive of neurologic disability. While the 2010 examiner reported decreased grip strength is due to carpal tunnel syndrome, there was no discussion of the pain and symptoms originating in the neck area. The 2015 examiner inconsistently reported that the Veteran claimed to have pain radiating to his left upper extremity, but then reporting that there were no symptoms of radiculopathy. Further, this examiner did not consider the extensive treatment in 2010 and 2011, which included treatment of the upper extremities and discussion of the radiating pain. Remand is required in order to afford the Veteran a new VA examination of his cervical spine with adequate consideration of the record and of the Veteran's reported radiating symptoms. Hypertension In June 2015, the Board remanded the matter of whether service connection is warranted for hypertension for an examination to assess the nature and etiology of any hypertension present. The examiner was to determine whether it is as likely as not that the hypertension is related to the Veteran's period of military service, and whether it is as likely as not that the Veteran's hypertension was due to or aggravated by the service-connected cervical spine disability, to include an assessment as to whether the hypertension was the result of rising cortisol levels triggered by pain in his cervical spine. See December 2013 VA Form 9. In February 2009, Dr. G.I. indicated a possibility that episodes of hypertension experienced were related to his elevated cortisol level. In August 2015, the Veteran underwent a VA examination. The examiner confirmed the hypertension as having been diagnosed in 2009. This is inaccurate, as discussed in further detail, below. Moreover, in reporting the Veteran's history, the examiner noted, "see blank template for medical history, narrative and details." No such document is of record, thus it is unclear what history the examiner's opinion was based upon. The examiner went on to provide the following opinion, "Essential hypertension (Icd9 code: 401). No functional limitation. Condition not caused by service or SC condition. Condition not caused by or aggravated by medical literature. Acute elevation of any vital signs is deemed an expected normal response and dos [sic] not constitute an 'aggravation' of the condition, as is being trying to imply [sic] based on comments made on Feb 2009 - such a statement has no biological/physiological support." This opinion, in addition to being largely incomprehensible, does not address the questions posed in the Board's remand directives. In sum, the August 2015 VA examination report is devoid of probative value and inadequate for the purposes of an analysis of this service connection issue. In October 2015, another VA examiner provided an addendum opinion indicating it is less likely as not that the Veteran's hypertension is caused by or a result of active military service, "because his hypertension is caused by genetic predisposition for it." No discussion of any in-service indicators of hypertension, or of the Veteran's contentions related to the relationship between the hypertension and the cervical spine disability were discussed. This report also lacks probative value. Neither examiner discussed the Veteran's in-service blood pressure readings, which included normal findings at entrance into service, but a December 1994 blood pressure reading of 159/76. Moreover, the report of a March 2001 retirement physical includes an indication of a history of pain or pressure in the chest. The physician noted that the Veteran reported experiencing chest tightness following treatment for his cervical spine. Following service, in August 2004, the Veteran was seen in an emergency room due to experiencing chest pain. In an August 2004 follow-up note, his blood pressure was measured as 143/87 and "borderline blood pressure" was indicated. He was started on Zocor at that time. December 2004 family clinic notes show the diagnosis of hypertension as established and medication was continued. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). On remand, the Veteran should be afforded a new VA examination to assess the nature and etiology of his hypertension, to include consideration of the service treatment records, the Veteran's history of hypertension since service, and the Veteran's contentions related to secondary service connection. Left Carpal Tunnel Syndrome In June 2015, the Board remanded the matter of whether service connection is warranted for left carpel tunnel syndrome for an opinion as to causation. In particular, the Board required an opinion as to whether the Veteran's currently diagnosed left carpal tunnel syndrome was aggravated by the service-connected cervical spine disability. In August 2015 and October 2015, a VA examiner confirmed the diagnosis of left carpal tunnel syndrome and provided several opinions. The examiner found that it is less likely than not that the Veteran's carpel tunnel syndrome, which was diagnosed in 2008, was caused by in-service hard parachute landing, because such landing is not a recognized cause of carpal tunnel syndrome. The examiner also noted the onset as six years after the Veteran's separation from active service. As to aggravation by the cervical spine disability, the examiner found it, "is less likely as not that the left carpel tunnel syndrome (a regional syndrome due to pressure on the median nerve in the carpel tunnel at the WRIST) is aggravated beyond natural progression by his cervical condition in the neck, because of lack of medical nexus." The examiner's rationale in this regard is undoubtedly inadequate. The examiner essentially explained that there is no nexus because of a "lack of medical nexus." This is not a well-reasoned rationale, which is required. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Thus, this issue must be remanded for an addendum opinion. Accordingly, the case is REMANDED to the RO or the Appeals Management Center (AMC), in Washington, D.C., for the following actions: 1. The RO or the AMC should undertake appropriate development to obtain any outstanding, pertinent VA and private medical records. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Once the record is developed to the extent possible, afford the Veteran a VA examination by a physician qualified to conduct a VA neurological examination of the Veteran's cervical spine and upper extremities. This examination should be conducted to both determine the current severity and manifestations of the Veteran's cervical spine disabilities to include any upper extremity neurologic impairment, and to provide a comprehensive analysis of the history of the severity of the Veteran's cervical spine neurologic impairment since the inception of the Veteran's claim in January 2010. The examiner should determine whether at any time since January 2010 the Veteran's service-connected cervical spine disability has been manifested by any neurologic impairment. In particular, the examiner should assess the various symptoms shown throughout the record, to include the radiating pain originating in the neck described in the 2010 VA examination report, the 2010 and 2011 clinical records and surgical report, and the 2015 examination report, and determine the appropriate diagnosis related to those symptoms, and an opinion as to whether any diagnosed disorder is or is not a manifestation of the service-connected cervical spine disability. All pertinent evidence must be made available to and reviewed by the examiner, and any indicated studies should be performed. The RO or the AMC should ensure that all information required for rating purposes is provided by the examiner. The rationale for all opinions expressed must also be provided. 3. Once the record is developed to the extent possible, afford the Veteran a VA examination by a physician with sufficient expertise to determine the etiology of the Veteran's claimed hypertension. Based on review of the record, the examiner should state a medical opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that the Veteran's currently diagnosed hypertension originated during his active service or is otherwise etiologically related to his active service. The physician should consider the Veteran's in-service blood pressure readings, as well as the report of a history of chest pain at the time of his retirement examination. If the examiner determines that the Veteran's hypertension is not connected to his active service, the examiner also should provide an opinion as to whether there is a 50 percent or better probability that the Veteran's hypertension was caused or permanently worsened by his cervical spine disability, to include (1) due to the contention that the cervical spine pain causes rise in cortisol levels, which causes hypertensive episodes and (2) consideration of the retirement examination report noting chest pain after treatment of the cervical spine. The supporting rationale for all opinions expressed must be provided. If the examiner is unable to provide any required opinion, he or she should explain why the required opinion cannot be provided. 4. Once the record is developed to the extent possible, all pertinent evidence of record must be made available to and reviewed by either the examiner who conducted the August 2015 left carpal tunnel examination, or the examiner who provided the October 2015 addendum, if available. Based on review of the record, the examiner should state a medical opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that the Veteran's currently diagnosed left carpel tunnel syndrome originated during his period of active service or is otherwise etiologically related to his active service. If the examiner determines that the Veteran's left carpel tunnel syndrome is not connected to his active service, the examiner also should provide an opinion as to whether there is a 50 percent or better probability that the Veteran's left carpel tunnel syndrome was caused or permanently worsened by any aspect of his cervical spine disability. The supporting rationale for all opinions expressed must be provided. If the examiner is unable to provide any required opinion, he or she should explain why the required opinion cannot be provided. If the prior examiners are unavailable, all pertinent evidence of record should be made available to and reviewed by another health care professional with appropriate expertise who should be requested to provide the required opinion(s) with supporting rationale. Another examination of the Veteran should only be performed if deemed necessary by the person providing the opinion(s). 5. The RO or the AMC should also undertake any other development it determines to be warranted. 6. Then, the RO or the AMC should readjudicate the Veteran's claims. If the benefits sought on appeal are not granted to the Veteran's satisfaction, a supplemental statement of the case should be issued to the Veteran and his representative, and they should be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. The Veteran need take no action until he is otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This REMAND must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs