Citation Nr: 1625508 Decision Date: 06/27/16 Archive Date: 07/11/16 DOCKET NO. 11-29 283 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a lumbar spine disability. 2. Entitlement to service connection for a bilateral eye disability. 3. Entitlement to service connection for a bilateral foot disability. 4. Entitlement to service connection for a heart disability. 5. Entitlement to service connection for neurosyphilis and syphilis, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 6. Entitlement to service connection for a disability manifested by dizziness and weakness, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 7. Entitlement to service connection for occipital neuralgia, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Mary C. Suffoletta, Counsel INTRODUCTION The Veteran served on active duty from July 1977 to July 1980 and from July 1991 to April 1992, including service in Southwest Asia from July 1991 to November 1991. These matters come to the Board of Veterans' Appeals (Board) on appeal from a January 2009 decision of the RO and subsequent decisions that denied service connection for low back pain, for presbyopia, for fractured left second toe, for dizziness and weakness, and for a heart condition; from a June 2009 rating decision that denied service connection for occipital neuralgia; and from an October 2010 rating decision that denied service connection for neurosyphilis. The Veteran timely appealed. In February 2015, the Veteran testified during a video conference hearing before the undersigned. During the hearing, the undersigned granted the Veteran's request for a 60-day abeyance to submit additional evidence or argument directly to the Board. In March 2015 and again in July 2015, the Veteran submitted additional evidence to the Board. The Board accepts that evidence for inclusion in the record. See 38 C.F.R. § 20.709 (2015). The Board notes that the U.S. Court of Appeals for Veterans Claims has held that the Board must broadly construe claims, and consider other diagnoses for service connection when the medical record so reflects. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Accordingly, because the Veteran claimed service connection for residuals of fracture of left second toe and had been diagnosed with bilateral hallux valgus, the issue on the title page reflects the expanded issue on appeal as a result of the Clemons decision. Moreover, service connection for status-post residuals of fracture of right great toe has already been awarded. As such, the issue is captioned as above on the title page. In September 2014, the RO severed service connection for chronic fatigue syndrome. The record reflects no notice of disagreement, with that rating decision; and the issue has not been certified for appellate consideration. As such, the matter is not in appellate status and will not be addressed by the Board. The issues of service connection for disabilities manifested by fatigue, headaches, muscle aches, pain, neurological symptoms in extremities, cognitive dysfunction, and mood and sleep disturbance, have been raised by the record in an October 2010 statement (claimed as Gulf War Syndrome), but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). The issues of service connection for a lumbar spine disability; for neurosyphilis and syphilis; for a disability manifested by dizziness and weakness; and for occipital neuralgia, are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran had active service in the Southwest Asia Theater of operations (SWA) during the Persian Gulf War. 2. The Veteran does not have an undiagnosed illness, characterized by vision problems; and currently diagnosed presbyopia is a refractive error, and is not otherwise related to a disease or injury during active service-to include service in SWA. 3. A bilateral foot disability, to include hallux valgus, did not have its onset in service and did not increase in severity during active service; and arthritis of both feet was neither shown by X-ray, nor manifested to a compensable degree, within the first post-service year. 4. The Veteran does not have an undiagnosed illness, characterized by cardiovascular problems; and does not have a disability manifested by a racing heartbeat that either had its onset in active service, or is otherwise related to a disease or injury during active service-to include service in SWA. CONCLUSIONS OF LAW 1. A disability manifested by vision problems, to include as a disability due to undiagnosed illness, was not incurred or aggravated in service; and presbyopia is not a disease or injury within the meaning of the law providing compensation, and was not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 1117, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2015). 2. A bilateral foot disability, to include hallux valgus, was not incurred or aggravated in service; and may not be presumed to have been incurred therein, and is not proximately due to or the result of a disease or injury attributable to service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, 3.310 (2015). 3. A disability manifested by cardiovascular problems, to include as a disability due to undiagnosed illness, was not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 1117, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). VA's duty to notify was satisfied by September 2008, March 2009, June 2010, March 2011, and March 2013 letters. See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Each of the Veteran's claims decided on appeal has been fully developed and re-adjudicated by an agency of original jurisdiction after notice was provided. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board concludes that VA's duty to assist has been satisfied. All available records identified by the Veteran as relating to each of his claims have been obtained, to the extent possible. The RO has obtained the Veteran's service treatment records and outpatient treatment records, and has arranged for VA examinations in connection with the claims decided on appeal, reports of which are of record and appear adequate. The opinions expressed therein are predicated on a substantial review of the record and consideration of the Veteran's complaints and symptoms. The Veteran has not identified, and the record does not otherwise indicate, any existing pertinent evidence that has not been obtained. During the hearing the undersigned clarified the issues, explained the concept of service connection, and helped to identify any pertinent evidence that was outstanding that might substantiate the claims. The actions of the undersigned supplement VA's duties and comply with 38 C.F.R. § 3.103. Given these facts, it appears that all available records have been obtained. There is no further assistance that would be reasonably likely to assist the Veteran in substantiating the claims. 38 U.S.C.A. § 5103A(a)(2). II. Analysis Service connection is awarded for disability that is the result of a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. Id. The Federal Circuit has held that section 3.303(b) applies only to those chronic conditions specifically listed in 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Specific to Persian Gulf War service, service connection may be granted for objective indications of a chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms-to include headache, neurological signs or symptoms, and cardiovascular signs or symptoms. The chronic disability must have become manifest either during active military, naval, or air service in the Southwest Asia Theater of operations (SWA) during the Persian Gulf War, or to a degree of 10 percent or more disabling not later than December 31, 2016, and must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317; see 76 Fed. Reg. 81,834 (Dec. 29, 2011) (interim final rule extending statutory period). A Persian Gulf Veteran is a Veteran who served on active military, naval, or air service in SWA during the Persian Gulf War. 38 U.S.C.A. § 1117(e); 38 C.F.R. § 3.317(d). In this case, the Veteran's DD Form 214 shows service in SWA, and confirms receipt of the Southwest Asia Service Medal. This medal generally indicates service in the area and time period referenced under 38 C.F.R. § 3.317. When assessing the probative value of a medical opinion, the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical opinion that contains only data and conclusions is not entitled to any weight. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). A. Bilateral Eye Disability Here, the report of a January 2009 VA examination reflects a diagnosis of presbyopia of both eyes. Because the January 2009 examiner attributed the Veteran's bilateral eye disability to a known clinical diagnosis, his presbyopia of both eyes cannot be considered an undiagnosed illness or a qualifying chronic disability for entitlement to service connection based on the Veteran's service in the Persian Gulf. As for service connection on a direct basis, the Veteran's enlistment examination in November 1976 reveals defective vision, both far and near. His service treatment records, dated in September 1971, show that gasoline accidentally splashed into the Veteran's eyes. Specifically, the Veteran had been putting gasoline into a container, and the nozzle came out of the can and spilled gasoline all over the Veteran. The Veteran went to the Emergency Room. Objective evaluation at the time revealed that the Veteran's eyes were reddened at lids and to sclera with increased tearing. The Veteran had difficulty keeping his eyes open, and complained of a burning sensation. His eyes were flushed on site by medics, and follow-up treatments were required. Post-service records show that the Veteran reported the in-service incident of burning and stinging of both eyes during a January 2009 VA examination. He reported that his eyes were flushed at the time and ointment was inserted. Current symptoms in January 2009 included blurry vision and flashers in each eye. Examination revealed that the Veteran's uncorrected distance vision for each eye was 20/20; and uncorrected near vision for each eye was 20/70, corrected to 20/20. Muscle function revealed neither strabismus nor diplopia present. Slit lamp examination findings were normal, and there were no visual field defects. The diagnosis was history of gasoline to eyes, healed without sequelae. The January 2009 examiner diagnosed presbyopia of both eyes, and opined that the condition was not related to exposure sustained in active service. In support of the opinion, the January 2009 examiner reasoned that presbyopia is a natural aging process of the lens that results in decreased accommodation and reading ability. The report of a June 2011 VA examination includes a finding of bilateral dry eye. In February 2015, the Veteran testified that his eyes were treated with medications in active service; and that he did not have any surgery on his eyes. In March 2015, a private physician opined that the Veteran's "partial blindness right eye" was related to an onset or events while in active service, and caused by or a result of the Veteran's service in Desert Storm and Gulf War region. Under 38 C.F.R. § 3.303(c), congenital or developmental abnormalities, and refractive error of the eye, are not considered diseases or injuries within the meaning of applicable legislation governing the awards of compensation benefits. As presbyopia is a refractive error, this condition is not a disease or injury for purposes of service connection. See McNeely v. Principi, 3 Vet. App. 357, 364 (1992); Parker v. Derwinski, 1 Vet. App. 522 (1991). While service connection may be granted, in limited circumstances, for superimposed disability on a constitutional or developmental abnormality (see VAOPGCPREC 82-90, 55 Fed. Reg. 45,711 (1990); see also Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993)), there is no evidence whatsoever that such occurred in this case. The January 2009 examiner specifically indicated that the Veteran's history of gasoline to eyes had healed without residuals. In short, the evidence does not reflect aggravation or a superimposed disability. The Board also finds the January 2009 opinion to be persuasive in finding that the current presbyopia was not related to exposure sustained in active service. The VA examiner reviewed the medical history and provided a rationale. The Board finds that the opinion in the January 2009 examination report is factually accurate, fully articulated, and contains sound reasoning. Therefore, the opinion is afforded significant probative value. Nieves-Rodriguez, 22 Vet. App. at 304. In contrast, the March 2015 opinion by the private physician is of minimal probative value because no rationale is provided. While the Veteran is competent to report symptoms, he is not competent to provide an etiology opinion linking current presbyopia to active service, as this is beyond the capacity of a lay person to observe. Moreover, even if he were competent to render a diagnosis and opinion, his opinion is outweighed by the January 2009 examiner's opinion that current presbyopia is not related to disease or injury in active service. The examiner's opinion is entitled to greater probative weight as the examiner reviewed the history, conducted a physical examination, and provided an opinion that is supported by a rationale. In short, for the reasons and bases set forth above, the Board concludes that the evidence weighs against granting service connection for a bilateral eye disability. On this matter, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Bilateral Foot Disability The Veteran testified that a generator had fallen on his feet in active service and broke bones in his feet. He testified that one toe was going into another, and that he had to have surgery in 2011 or 2012 to straighten it out. He testified that he still had intermittent pain and took medication at times. He is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). Service treatment records show that a trailer had fallen on the Veteran's right foot and cut the lateral aspect of the dorsal great toe in September 1991. X-rays taken at that time were positive for fracture, without displacement. As noted above, service connection has already been awarded for status-post residuals of right great toe fracture. Service treatment records do not reflect any findings or complaints of injury or fracture of the left second toe. Nor is there any finding of hallux valgus in active service. There is no evidence of arthritis manifested in service or to a compensable degree within the first post-service year. See 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2015). The report of a June 2011 VA examination includes diagnoses of right great toe residuals status-post fracture, and bilateral hallux valgus. The June 2011 examiner opined that it would be only with resort to mere speculation to opine whether the Veteran's current bilateral hallux valgus was caused or aggravated to any degree by his active service. The June 2011 examiner noted that service treatment records are silent for any hallux valgus, and there is no current objective evidence that hallux valgus was caused or aggravated to any degree by the Veteran's active service. VA records show that the Veteran complained of pain to the right great toe of two-to-three months' duration in August 2011. Evaluation in October 2011 revealed right hallux abductovalgus, right mild first metatarsophalangeal joint arthralgia, right EHL (extensor hallucis longus) tendonitis, and bilateral pes planus. In February 2012, the Veteran underwent a right modified McBride bunionectomy with first metatarsal osteotomy and internal screw fixation. The report of a July 2013 VA examination shows a diagnosis of hallux valgus of each foot, and indicates that the Veteran underwent a surgical metatarsal head resection in 2012. The Veteran regularly used a cane for walking and balance issues. Examination revealed no symptoms due to the hallux valgus condition. Following examination, the July 2013 examiner opined that the in-service fractured great right toe is not causally related to the bunionectomy of the right hallux abductovalgus. In support of the opinion, the examiner reasoned that the Veteran has hallux valgus of the left foot as well. The Board has considered the findings by the June 2011 and July 2013 VA examiners, which are against a relationship between the Veteran's current bilateral hallux valgus and active service. The examination reports are fully articulated and contain sound reasoning. The Board finds the July 2013 VA examiner's opinion to be persuasive in finding that the Veteran's current bilateral hallux valgus is not a residual of, or related to the events in active service. Notably, the Veteran specifically denied having any foot trouble during his service in the Army Reserves in April 1997. There is no medical evidence of record that demonstrates the existence of any bilateral foot disability prior to the Veteran's active service. Nor is there evidence of an increase in severity or of any worsening of a bilateral foot disability during active service or within the first post-service year, to demonstrate or support a finding of aggravation. Neither VA examiner found any permanent, measurable increase in the severity of a bilateral foot disability that could be attributed to active service. The July 2013 VA examination report shows that the Veteran regularly used a cane for walking and for balance issues. There are no symptoms due to the hallux valgus condition of either foot. The examination report is fully articulated and contains sound reasoning. The Board finds the July 2013 VA examiner's opinion to be persuasive in finding that the Veteran's current bilateral hallux valgus is not causally related to the in-service fractured toe. The Board finds the July 2013 examiner's opinion supported by the record-namely, the September 1991 in-service treatment record of a right great toe fracture, and the April 1997 Army Reserves record of no foot trouble-and is responsive to the question at hand. The Board notes the Veteran's sincere belief that his current bilateral foot disability originated during active service. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, his opinion is outweighed by the July 2013 examiner's opinion that current complaints of bilateral foot pain are not related to active service. The July 2013 examiner's opinion is entitled to greater probative weight as the examiner reviewed the Veteran's medical history, conducted a physical examination, and provided an opinion that is supported by a rationale. Again, the benefit-of-the-doubt rule does not apply, and the claim for service connection for a bilateral foot disability must be denied. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. 53-56. C. Heart Disability Service treatment records reveal a normal heart and vascular system on clinical evaluation in July 1980, at the time of the Veteran's separation examination from his first period of active service. On a "Report of Medical History" completed by the Veteran in April 1986 and again in April 1997 during Army Reserves service, he checked "no" in response to whether he ever had or now had palpitation or pounding heart or heart trouble or high or low blood pressure. There is no evidence of cardiovascular-renal disease during active service or manifested to a compensable degree within the first post-service year. See 38 U.S.C.A. §§ 1101, 1110, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2015). Here, private records show that the Veteran underwent evaluation for coronary insufficiency in September 2008. Records at that time reflect findings of bradycardia (slow heart rate). No heart disease was found. VA records first show treatment for racing heartbeat in November 2008. At that time the Veteran reported dizziness, heart racing, and sharp pains in his left chest and left leg, on and off, since September 2008. Records show that he was given a heart monitor. During a June 2011 VA examination, the Veteran reported that he began to feel palpitations and irregular heartbeats in the fall of 2008. Since then, the condition has been stable. The Veteran reported no history of myocardial infarction, rheumatic fever, hypertension, hypertensive heart disease, heart rhythm disturbance, valvular heart disease including prosthetic valve, congestive heart failure, other heart disease, angina, syncope, or dyspnea. The Veteran did report a positive history of dizziness and fatigue. Following examination and diagnostic testing, the June 2011 examiner noted findings of physiologic sinus bradycardia and atrial premature complexes without any current objective evidence for any cardiac pathology. No other cardiac condition was found. A stress test was not clinically indicated. No heart diagnosis was rendered. The June 2011 examiner opined that it would be only with resort to mere speculation to opine whether the Veteran's current heart condition was caused or aggravated to any degree by his environmental exposures during deployment in SWA or by the Veteran's active service. The June 2011 examiner noted that service treatment records are silent for any cardiac symptoms, treatments, or diagnoses; and there is no current objective evidence that the Veteran's heart condition was caused or aggravated to any degree by the Veteran's active service. Moreover, current medical literature does not support a cause-and-effect relationship between the environmental exposures in SWA and subsequent development of any cardiac conditions or arrhythmias. In February 2015, the Veteran testified that he first experienced heart problems after his service in Desert Storm during 2008. He testified that he was given medication to take, to "slow it up." When asked whether he took the medication on a regular basis, the Veteran testified that he took it "every time it feels like it's speeding up." He testified that when he became sick, his heart raced and he took medication. In March 2015, a private physician opined that the Veteran's heart condition was related to an onset or events while in active service, and caused by or a result of the Veteran's service in Desert Storm and Gulf War region. The Board finds this opinion of minimal probative value because no rationale is provided. The Veteran is competent to testify as to symptoms he has experienced that are capable of lay observation, such as a racing heartbeat. The question therefore becomes whether a disability manifested by cardiovascular signs or symptoms has become manifest to a degree of 10 percent or more disabling since his service in SWA. For the reasons outlined below, the Board finds that one has not. The diagnostic criteria applicable to evaluating diseases of the heart are found in 38 C.F.R. § 4.104. Several diagnostic codes (DC) relate to the cardiovascular system and are explained herein, to the extent of reaching the required 10 percent disability threshold. Primarily, a 10 percent rating is warranted for diseases of the heart where, (1) stress test results demonstrate, generally, a workload of greater than 7 METs (metabolic equivalents) but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness or syncope, or; (2) when continuous medication is required. In this case, the June 2011 examiner found that a stress test was not clinically indicated; hence, there are no MET findings. Rather, the Veteran testified that he took medication for a racing heart at times when he was sick. There is no evidence that continuous medication is required for a racing heart. The condition, apparently, has become stable. While there are findings of bradycardia in the record, the evidence does not demonstrate that any heart disease manifested to a degree of 10 percent or more at any time since the Veteran's active service in SWA. The Board notes that cardiovascular signs or symptoms are objective signs of undiagnosed illness or a chronic multisymptom illness. 38 C.F.R. § 3.317(b). Here, although the Veteran has complained of a racing heartbeat, those complaints have not been associated with any cardiac pathology or other objective signs or symptoms that are compensably disabling. While the Veteran is credible in his descriptions, he has not exhibited symptomatology of a compensable nature that would warrant a finding of undiagnosed illness. In sum, the normal findings in service treatment records and Army Reserves records establish that a heart disease was not "noted" during active service or within the first post-service year. In addition, the Veteran did not have characteristic manifestations sufficient to identify a chronic disease entity. In fact, despite his complaints, no cardiac disease or injury has ever been identified. Rather, the Veteran has bradycardia (a slow beat), which has been determined to be physiologic in this case. The private medical opinion that there is a relationship to his service in SWA is remarkable for its lack of reasoning. Nothing in the record reflects that findings of bradycardia have resulted in disability (impairment) or rise to a compensable level. For the reasons and bases set above, the Board concludes that the evidence weighs against granting service connection for a heart disability. ORDER Service connection for a bilateral eye disability, to include presbyopia, is denied. Service connection for a bilateral foot disability, to include hallux valgus, is denied. Service connection for a heart disability is denied. (CONTINUED ON NEXT PAGE) REMAND Records Most of the Veteran's service treatment records, including his entry and exit examinations for his second period of active service from July 1991 to April 1992, are not in the claims file. The RO or VA's Appeals Management Center (AMC) should make another attempt to locate these service treatment records, and associate them with the Veteran's claims file. VA is obliged to assist a Veteran to obtain evidence pertinent to his claims. See 38 U.S.C.A. § 5103A (West 2014). Lumbar Spine Disability The Veteran contends that service connection for a lumbar spine disability is warranted on the basis that the onset of his low back pain was during active service in Fort Knox, Kentucky; and that he continues to have low back pain. The Veteran is competent to describe his symptoms. There is no evidence of treatment in active service for any lumbar spine disability. No such disability was noted at the time of the Veteran's separation examination in July 1980, following his initial period of active service. The Veteran's Army Reserves records show that he reported recurrent back pain in April 1997. VA records show complaints of low back pain in May 2011. In March 2015, a private physician opined that the Veteran's L5 disc disability was related to an onset or events while in active service, and caused by or a result of the Veteran's service in Desert Storm and Gulf War region. Under these circumstances, the Board finds that an examination is needed to determine whether the Veteran has a current lumbar spine disability that either had its onset during service or is related to his active service. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(4) (2015). Neurosyphilis and Syphilis The Veteran contends that service connection for neurosyphilis and syphilis is warranted on the basis that, after serving in SWA, he had an infection and sought treatment. He later was diagnosed with syphilis in 2008 and treated for the infection. The Veteran is competent to describe his symptoms. VA is required to seek a medical opinion if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but contains competent lay or medical evidence of a current disability, establishes that the Veteran suffered an event, injury or disease in service, and indicates that the current disability may be associated with the in-service event, injury or disease. 38 C.F.R. § 3.159(c)(4) (2015). The Veteran's Army Reserves records, dated in April 1997, show that the Veteran checked "no" in response to whether he ever had or now had syphilis. VA records show that the Veteran was hospitalized for neurosyphilis in May 2010, and that he continued to undergo treatment in May 2011. The report of a June 2011 VA examination reflects that the Veteran reported being suddenly weak in September 2008, and that he was hospitalized. A medical workup at the time revealed positive titers for staph infection requiring antibiotics therapy. Although the infection cured, some neurological residuals have continued. Symptoms reported by the Veteran include confusion, depression, inability to concentrate, and sleep disturbance. Following examination and testing, the diagnosis was status-post treatment of neurosyphilis. The June 2011 examiner noted that service treatment records are silent for any symptoms, treatment, or diagnosis of neurosyphilis or syphilis; and there is no current objective evidence that the Veteran contracted syphilis while in active service. His service treatment records also show a negative rapid plasma reagin (test for syphilis) in July 1980. While the June 2011 examiner provided an adverse opinion, in this case, the Board notes that the examiner did not address the etiology of the Veteran's claimed infection; and whether or not it had its onset in active service or within the first post-service year, and whether an in-service infection attributed to the Veteran's development of neurosyphilis and syphilis. Under these circumstances, the Board finds that an addendum opinion is needed to determine whether the Veteran has current neurosyphilis or syphilis that either had its onset during service or is related to his active service. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(4) (2015). Dizziness and Weakness, and Occipital Neuralgia The Board finds the Veteran's claims for service connection for a disability manifested by dizziness and weakness, and for occipital neuralgia are inextricably intertwined with the pending issue for service connection for neurosyphilis and syphilis, at this time. Thus, appellate review of the issues of service connection for a disability manifested by dizziness and weakness, and for occipital neuralgia must be deferred until resolution of the service connection for neurosyphilis and syphilis claim. Accordingly, the case is REMANDED for the following action: 1. Undertake appropriate action to obtain the Veteran's complete service treatment records for his second period of active service from July 1991 to April 1992, and associate them with the claims file. 2. Afford the Veteran a VA examination to identify all current disability underlying the Veteran's current complaints of low back pain; and the likely etiology of each disease or injury. (a) For any current disability identified, the examiner(s) is requested to determine whether it is at least as likely as not (50 percent probability or more) that it is the result of disease or injury incurred during active service-specifically, to include service in SWA; and the Veteran's account of continuing symptoms of low back pain since then. (b) Whether it is at least as likely as not (50 percent probability or more) that the Veteran's service-connected status-post residuals of right great toe fracture and tinea corpora (1) caused or (2) aggravated (i.e., permanently increased in severity beyond the natural progress) any current lumbar spine disability, beyond the natural progress. The examiner(s) should provide a rationale for the opinions. The examiner(s) is asked to explain the reasons behind any opinions offered. The examiner(s) is also reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 3. The June 2011 VA examination report should be returned to the examiner (or, if that examiner is unavailable, an appropriate substitute) for an addendum opinion as to the likely etiology of the Veteran's neurosyphilis or syphilis. The examiner(s) is requested to determine: Whether it is at least as likely as not (50 percent probability or more) that the Veteran's neurosyphilis or syphilis is the result of disease or injury incurred during active service-specifically, to include an in-service infection, as reported by the Veteran, and service in SWA; and the Veteran's account of continuing symptoms of neurosyphilis or syphilis post-service during the pendency of the claim. The examiner(s) should provide a rationale for the opinion. If the examiner(s) or substitute deems it advisable to conduct a further in-person examination of the Veteran, then such an examination should be scheduled and conducted. 4. After ensuring that the requested actions are completed, re-adjudicate the claims on appeal-to include the inextricably intertwined claims for service connection for a disability manifested by dizziness and weakness, and for occipital neuralgia. If the benefits sought are not fully granted, furnish a SSOC before the claims file is returned to the Board, if otherwise in order. No action is required of the Veteran and his representative until they are notified by the RO or AMC; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claims. 38 C.F.R. § 3.655 (2015). The Veteran has the right to submit additional evidence and argument on the matter that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs