Citation Nr: 1714129 Decision Date: 05/01/17 Archive Date: 05/11/17 DOCKET NO. 12-06 828 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for sinusitis. 2. Whether new and material evidence has been received to reopen the claim for service connection for pseudofolliculitis barbae. 3. Entitlement to higher ratings for lumbar spine disability, currently rated 20 percent for limitation of motion; 60 percent for neurogenic bladder from August 23, 2013; 60 percent for bowel incontinence from September 3, 2013; 10 percent each for right and left lower extremity lumbar radiculopathy from April 4, 2013, and 20 percent from March 21, 2016. 4. Entitlement to a rating in excess of 10 percent for gastroesophageal reflux disease. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD C. Lawson, Counsel INTRODUCTION The Veteran served on active duty from August 1973 to March 1996. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran is currently assigned a 20 percent rating for lumbar spine disability based on limitation of motion of the thoracolumbar spine from the September 20, 2011 date of claim to present. He has also been awarded a 60 percent rating for neurogenic bladder from August 23, 2013 and a 60 percent rating for incontinence of bowel, both due to his lumbar spine disability, from September 3, 2013. He has also been awarded two 10 percent ratings, one each for right and left lower extremity lumbar radiculopathy, from April 4, 2013, and two 20 percent ratings, one each for right and left lower extremity radiculopathy from March 21, 2016, both due to lumbar spine disability. Ratings based on neurological impairment caused by lumbar spine disability will be considered in this decision, consistent with 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1) (2016), for the period of time from the September 11, 2011 date of the claim for service connection for lumbar spine disability to present, as part of the Veteran's appeal for the highest rating possible for his service-connected lumbar spine disability from its claim date. AB v. Brown, 6 Vet. App. 35 (1993). The issues of entitlement to a rating in excess of 10 percent for gastroesophageal reflux disease and entitlement to service connection for sinusitis are addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. The RO last denied service connection for pseudofolliculitis barbae in July 2010 and notified the Veteran of its decision and of his right to appeal it within 1 year thereof at the time. The Veteran did not perfect an appeal, nor was new and material evidence received within one year of the notification of the decision at the time. 2. Since the final July 2010 decision denying service connection for pseudofolliculitis barbae, evidence relating to an unestablished fact necessary to substantiate the claim and which is neither cumulative nor redundant of the evidence of record at the time of the last prior denial of the claim has been received. 3. The Veteran's current pseudofolliculitis barbae was not manifest in service and is unrelated to service. 4. Prior to June 7, 2013, the Veteran did not have forward flexion of his thoracolumbar spine limited to 30 degrees or less. 5. From June 7, 2013 to May 15, 2016, the Veteran had thoracolumbar spine forward flexion limited to 30 degrees or less; he did not have unfavorable ankylosis of his entire thoracolumbar spine. 6. From May 16, 2016 to present, the Veteran does not have forward flexion of his thoracolumbar spine limited to 30 degrees or less. 7. From August 23, 2013, the Veteran's neurogenic bladder has not been manifested by any symptom not specifically contemplated by the schedular rating criteria. 8. From September 3, 2013, the Veteran's bowel incontinence has not more nearly approximated complete loss of sphincter control. 9. From September 28, 2012 to October 2, 2014, the Veteran had mild, but not moderate, incomplete paralysis of his right and left sciatic nerve. 10. From October 3, 2014, the Veteran has not had moderately severe or severe incomplete paralysis of his right or left sciatic nerve. CONCLUSIONS OF LAW 1. The July 2010 RO decision denying service connection for pseudofolliculitis barbae is final. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. § 20.1103 (2016). 2. The criteria to reopen the claim for service connection for pseudofolliculitis barbae based on new and material evidence are met. 38 U.S.C.A § 5108 (West 2014); 38 C.F.R. § 3.156 (a) (2015). 3. The criteria for service connection for pseudofolliculitis barbae are not met. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2016). 4. The criteria for a rating in excess of 20 percent for thoracolumbar spine limitation of motion prior to June 7, 2013 are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.40, 4.45, 4.71a, Diagnostic Code 5242 (2016). 5. The criteria for a 40 percent rating, but not higher, for thoracolumbar spine limitation of motion from June 7, 2013 to May 15, 2016, are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.40, 4.45, 4.71a, Diagnostic Code 5242 (2016). 6. The criteria for a rating in excess of 20 percent for thoracolumbar spine limitation of motion from May 16, 2016 are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.40, 4.45, 4.71a, Diagnostic Code 5242 (2016). 7. The criteria for a rating in excess of 60 percent for neurogenic bladder from August 23, 2013, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.115b, Diagnostic Code 7542 (2016). 8. The criteria for a rating in excess of 60 percent for neurogenic bowel from September 3, 2013, are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.114, Diagnostic Code 7332 (2016). 9. The criteria for 10 percent ratings, but not higher, for right and left lower extremity radiculopathy from September 28, 2012 to October 2, 2014, are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.124a, Diagnostic Code 8520 (2016). 10. The criteria for a 20 percent rating for right or left lower extremity radiculopathy, but no higher, are met from October 3, 2014. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.124a, Diagnostic Code 8520 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claims being decided herein, VA has met all statutory and regulatory notice and duty to assist provisions, and it has not been contended otherwise. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Pseudofolliculitis barbae The Veteran appeals for service connection for pseudofolliculitis barbae. Prior unappealed RO rating decisions are final. 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1103. Claims are to be reopened when new and material evidence is submitted. 38 U.S.C.A. § 5108. Applicable 38 C.F.R. § 3.156 provides that new evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering VA's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. For purposes of determining whether VA has received new and material evidence sufficient to reopen a previously-denied claim, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510 (1992). The RO denied service connection for pseudofolliculitis barbae in July 2010 and notified the Veteran of its decision and of his right to appeal it within 1 year at the time. The Veteran did not file a substantive appeal following the RO's March 2011 issuance of a statement of the case on the matter. Accordingly, the RO decision is final. See 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1103. The basis of the decision was that there was no evidence of pseudofolliculitis barbae in service, and no current diagnosis. Since that decision, the Veteran applied to reopen in September 2011, and medical records have been submitted showing current treatment for pseudofolliculitis barbae. Such evidence is new and material evidence as it is the type of evidence which was necessary but lacking at the time of the prior rating decision. Accordingly, the claim is reopened. Having determined that the claim for service connection for pseudofolliculitis barbae should be reopened, and as the RO considered the claim on the merits in the January 2015 statement of the case, the Board will now turn to the merits of the claim. On its merits, however, the claim should be denied, as there is no evidence of record which shows that the Veteran's current pseudofolliculitis barbae was manifest in or is related to service. To the contrary, service treatment records are silent for reference to pseudofolliculitis barbae, including at the time of the Veteran's March 1996 service discharge examination, when his skin was normal, and no evidence relates his current pseudofolliculitis barbae to service. The preponderance of the evidence is against the claim and there is no doubt to be resolved. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1991). Ratings for lumbar spine disability The claim for service connection for lumbar spine disability was received on September 11, 2011, and now, the questions before the Board concern the appropriate ratings to be assigned for it, including associated objective neurologic abnormalities, from that date to present. See Fenderson v. West, 12 Vet. App. 119 (1999), and Hart v. Mansfield, 21 Vet. App. 505 (2007). AB v. Brown, 6 Vet. App. 35 (1993). Disability ratings are based upon VA's Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity in civil occupations. 38 U.S.C.A. § 1155. The disability must be viewed in relation to its history. 38 C.F.R. § 4.1. A higher evaluation shall be assigned where the disability picture more nearly approximates the criteria for the next higher evaluation. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 U.S.C.A. § 4 .45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. The Veteran is currently assigned a 20 percent rating based on thoracolumbar spine limitation of motion. Under 38 C.F.R. § 4.71a's General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is warranted when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees but not greater than 335 degrees; or when there is muscle spasm or guarding not resulting in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted when there is forward flexion of the thoracolumbar spine only to 30 degrees or less; or when there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted when there is unfavorable ankylosis of the entire thoracolumbar spine. Note (1) to the General Rating Formula indicates to evaluate any associated objective neurologic abnormalities separately, under an appropriate Diagnostic Code. On VA back examination in November 2011, the Veteran's thoracolumbar spine forward flexion was to 55 degrees, with pain beginning at 40 degrees. Extension was to 15 degrees, with pain beginning at 10 degrees. Lateral flexion was to 20 degrees on the right and to 15 degrees on the left. All lower extremity deep tendon reflexes were normal, and sensory examination to light touch was normal for all dermatomes. The Veteran did not have any radicular signs or symptoms and did not claim to have any other neurological abnormality or findings related to a thoracolumbar spine condition, and he did not have intervertebral disc syndrome of his thoracolumbar spine. The Veteran denied having any bowel or bladder problems in relation to his spine. On VA evaluation on September 28, 2012, Veteran reported worsening back and leg pain. He reported that the pain was located over both sides of his lower back and hips, moving into his buttocks occasionally. The pain often shot down his legs to his calf, and was associated with numbness and tingling in his entire left foot. He also reported urinary incontinence several times a week that had been around for a number of years. He had associated perineal numbness in his scrotum, penis, buttocks, and perineal area that was associated with him sitting in certain positions. This problem had been going on for many years, but had gotten worse over the past year. On examination, his patellar reflexes were 2+. Achilles reflex could not be elicited. Strength was 4/5 with flexion and extension of the thigh. The Veteran was assessed with sciatic leg pain and tingling in his extremities. On VA evaluation on January 24, 2013, the Veteran complained of low back and left leg pain down to the ankle, with dysesthesia and intermittent weakness. Examination revealed normal strength but decreased sensation to light touch and an absent left ankle jerk. An outside MRI was noted to reveal an anterolisthesis at L4-L5 with moderate spinal stenosis. On April 9, 2013, the Veteran had normal motor bulk and tone and 5/5 strength. Sensation was decreased to light touch and pinprick throughout both feet, and the left leg also had decreased sensation over the dorsum and plantar aspects of the foot and into the lateral lower leg, sparing the anterior and medial lower leg. Upper legs had normal sensation. An April 9, 2013 record noted no bowel or bladder incontinence. On VA evaluation on June 7, 2013, the Veteran's lumbar flexion was to 30 degrees, extension and rotation were to 10 and 15 degrees left and right respectively, and side bending was to 15 degrees bilaterally. Muscle motor testing was 5/5 in the back and lower extremities, except for left ankle dorsiflexion and plantar flexion, which were each 4+/5. On VA neurology evaluation on June 18, 2013, the Veteran reported pain in his back and hips, radiating down his buttocks to his legs and feet from the back of the legs, left worse than right. Motor examination showed normal bulk and tone and 5/5 strength. Sensation was decreased to light touch and pinprick in both feet. The Veteran also had decreased sensation over the dorsum and plantar aspects of the left foot and lower leg. His upper legs had normal sensation. Coordination was normal. Patellar and Achilles reflexes were 2+ bilaterally. It was specifically noted "[n]o bowel or bladder incontinence." On VA evaluation in July 10, 2013, the Veteran's lumbar flexion was to 30 degrees, extension was to 10, and rotation and side bending were to 15 degrees bilaterally. Hamstrings strength and ankle dorsiflexion and plantar flexion strengths were each 5/5. A September 3, 2013 noted stated "[n]o bowel or bladder incontinence" although later the same record noted "[h]e has had some bowel and bladder incontinence for nearly a month now" and his primary care provider prescribed depends. A November 5, 2013 VA medical record notes normal motor bulk and tone and 5/5 strength in the lower extremities. Sensation was decreased to light touch and cold throughout both feet. Coordination was normal. Achilles was 1+ bilaterally and mute at the toes. He reported occasional bowel and bladder incontinence and a few accidents. A November 21, 2013 VA medical record states that the Veteran denied paralysis and paresthesias. A December 19, 2013 VA medical record shows that lower extremity strength was intact. Normal muscle bulk and tone were present. Deep tendon reflexes were 1-2+ bilaterally at L4 and 1+ bilaterally at S1. Sensation was intact to light touch. Lumbar radiculopathy was assessed. On December 19, 2013, strength was intact for hip and knee flexion and extension, and for ankle dorsiflexion and plantar flexion and great toe dorsiflexion and in the extensor hallucis longus. Deep tendon reflexes were 1-2+ bilaterally at L4 and 1+ bilaterally at L5. Sensation was intact for light touch. A December 27, 2013 VA medical record notes a several month history of urinary incontinence, and also occasional bowel incontinence. A December 27, 2013 urology consult noted a several month history of incontinence "mostly urge but sometimes imperceptible and occasional bowel incontinence. On June 6, 2014, the Veteran had 5/5 strength in his lower extremities bilaterally, and distal sensation was intact. An October 3, 2014, VA medical record shows that lumbar flexion was to 20 degrees. Hip flexion, extension, and abduction strength was 4+/5 on the right. Knee flexion and extension and ankle dorsiflexion were 5/5 on the right. Hip and knee flexion and extension were 3+/5 on the left. Hip abduction was 2+/5 on the left, and ankle dorsiflexion was 3/5. Sensation was grossly intact. On October 15, 2014, the Veteran reported bladder and bowel leakage daily. A December 19, 2014 VA medical record shows active lumbar range of motion to 15 to 20 degrees of flexion. It also shows right lower extremity strength was 3+ to 4+/5 for right hips flexion, extension, and abduction, 4 to 5/5 for knee flexion, 5/5 for knee extension, and 3 to 5/5 for ankle dorsiflexion. Left lower extremity strength was 3+ to 4-/5 for hip flexion and extension, 2+ to 3+ for hip abduction, 3+ to 4+/5 for knee flexion, 3+ to 4+/5 for knee extension, and 3 to 4-/5 for ankle dorsiflexion. Core stability was poor. A December 22, 2014 medical record noted that the Veteran had had "urinary and bowel incontinence since at least 1 year, wears depends." He worked full-time at a military facility as a briefer. That medical record noted that the Veteran had bladder incontinence "a couple x per week" and that he had bowel incontinence "less often, about once a week." On February 10, 2015, strength in the Veteran's lower extremities was 5/5 except for left hip and knee flexion and bilateral extensor hallucis longus and left plantar flexion, which were limited by pain. Knee and ankle jerks were absent. On March 24, 2015, a left lower extremity electromyogram revealed left lumbosacral radiculopathy with mild denervation. On June 18, 2015, the Veteran reported that he had burning pain in his hamstrings when standing, and burning in his lateral calves and occasional weakness and giving out in the left leg. He endorsed numbness and tingling in his groin and complete numbness of his legs when sitting, for 3 years. There was no radicular pain. He reported urinary and bowel urgency described as difficulty stopping once he felt the urge to go. He wore depends and a urine shield. Examination revealed decreased sensation on the lateral left lower extremity and dorsum/plantar aspect of the left foot. Strength was 5/5 in all extremities except that left hip and knee flexion and bilateral extensor hallucis long and left planter flexion were limited by pain. Deep tendon reflexes revealed absent ankle and knee jerks. The assessment was lumbar canal spinal stenosis. On July 8, 2015, patellar reflexes were 2+ on the right and 0 on the left. Strength was 4+/5 for right hip flexion, extension, and abduction, and 5/5 for knee flexion and extension and ankle dorsiflexion. On the left, hip flexion and extension and knee flexion were each 3+/5. Hip abduction was 2+/5, and ankle dorsiflexion was 3/5. On VA neurology consultation on July 30, 2015, the Veteran complained of lateral calf tingling, burning, and discomfort. Sensory was intact to light touch, except for hypesthesia bilaterally in the L5 distribution. Right and left iliopsoas motor strength was 5/5, and normal bulk and tone were present. Calf circumference was 46.5 bilaterally. Deep tendon reflexes were absent at the patella and ankle bilaterally. A December 2015 VA GI consultation report shows a history of urinary and fecal incontinence for 2-3 years. That month, the Veteran wrote a note to one of his treating providers, indicating that he was "having to use 5 to 10 depends per day and it is very embarrassing at work during interviews and briefings." He reported an incident during an important meeting where "[u]rine and feces were left on the floor at the agency." On VA back examination on May 16, 2016, forward flexion of the Veteran's thoracolumbar spine was to 55 degrees, and he could perform repetitive use testing without additional loss of function or range of motion. He had no muscle atrophy. Muscle strength testing was 5/5 throughout the lower extremities bilaterally. Knee reflexes were 2+ bilaterally at the knees and ankles. Sensation to light touch was normal in the lower extremities bilaterally. The Veteran was felt to have severe right and left lower extremity constant pain and intermittent pain due to radiculopathy; moderate right lower extremity paresthesias and/or dysesthesias, severe left lower extremity paresthesias and/or dysesthesias; mild right lower extremity numbness; and moderate left lower extremity numbness. He was found to have intervertebral disc syndrome. It had not required bed rest prescribed by a physician and treatment by a physician in the past 12 months. It caused difficulty sitting, standing, and walking at work. An October 2016 VA DBQ noted that the Veteran had impairment of rectal sphincter control. The VA examiner noted date of onset of the symptoms is 2012 and that the Veteran reported that the bowel problems began when the bladder incontinence started and has worsened over time. With respect to severity, the evaluator did not check a box consistent with the rating criteria, but instead marked "other" and described the disability as "3 incontinent BM daily." The examiner noted that the Veteran "[h]as to leave briefing/work to go to the rest room when incontinence occurs." Based on the evidence, the Board concludes that a prior to June 7, 2013, a disability rating in excess of 20 percent for thoracolumbar spine limitation of motion is not warranted under the General Rating Formula for Diseases and Injuries of the Spine. The evidence shows that prior to that date, the Veteran's thoracolumbar spine forward flexion had been to greater than 30 degrees, as evidenced by the 55 degrees of forward flexion shown on VA examination in November 2011. Next, the Board concludes that from June 7, 2013 to May 15, 2016, a 40 percent rating is warranted for thoracolumbar spine limitation of motion, as the evidence from that time period shows that the Veteran had forward flexion of his thoracolumbar spine limited to 30 degrees or less. It was 30 degrees on VA evaluations on June 7, 2013 and in July 2013, and only 20 degrees on VA evaluation in October 2014. A rating greater than 40 percent from June 7, 2013 to May 16, 2016, for lumbar spine limitation of motion, however, is not warranted, as the motion shown during this period demonstrates that the Veteran did not have unfavorable ankylosis of his entire thoracolumbar spine. Next, the Board concludes that from May 16, 2016 to present, no more than a 20 percent rating is warranted for thoracolumbar spine limitation of motion, as the Veteran had thoracolumbar spine flexion to 55 degrees on that date, and forward flexion of the thoracolumbar spine to 30 degrees or less is not otherwise shown from this point in time forward. The Board concludes that higher ratings than these cannot be assigned under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, as there is no evidence of incapacitating episodes of intervertebral disc syndrome as defined by Note (1) to that Formula. To the contrary, the VA examiner in November 2011 indicated that the Veteran did not have any intervertebral disc syndrome in his thoracolumbar spine, and the VA examiner in May 2016 indicated that the Veteran's intervertebral disc syndrome did not require bed rest prescribed by a physician and treatment by a physician in the past 12 months, and there is no contradictory evidence. Associated objective neurologic abnormalities will be considered next, consistent with Note (1) to the General Rating Formula. First, currently the Veteran has a 60 percent rating for neurogenic bladder from August 23, 2013. This is ratable under 38 C.F.R. § 4.115a, Diagnostic Code 7542 voiding dysfunction criteria. The criteria for rating neurogenic bladder require the wearing of absorbent pads which must be changed at least 2-4 times per day for a compensable rating based on voiding dysfunction. 38 C.F.R. § 4.115a. This is not shown prior to August 23, 2013, and so the criteria for a separate rating for neurogenic bladder prior to August 23, 2013 are not met. Additionally, the Veteran's neurogenic bladder is rated at the 60 percent maximum schedular rating from August 23, 2013, and so no higher schedular rating can be assigned for voiding dysfunction. The Veteran also has a 60 percent rating for incontinence of bowel from September 3, 2013. This is ratable under 38 C.F.R. § 4.115, Diagnostic Code 7332 for rectum and anus impairment of sphincter control. Bowel incontinence rating criteria provide for a 0 percent rating for healed or slight impairment, without leakage; a 10 percent rating for constant slight or occasional moderate leakage; a 30 percent rating for occasional involuntary bowel movements necessitating the wearing of a pad; a 60 percent rating for extensive leakage and fairly frequent involuntary bowel movements; and a 100 percent rating for complete loss of sphincter control. Prior to September 3, 2013, there is no clinical evidence of bowel incontinence that would warrant a separate rating. Further, there is no clinical evidence at any time that the Veteran has bowel incontinence more nearly approximating complete loss of sphincter control. The October 2016 examiner had an opportunity to check that box "complete loss of sphincter control" but failed to do so, instead describing 3 incontinent bowel movements per day. The preponderance of the evidence is against a finding of symptoms more severe than fairly frequent involuntary bowel movements. Next to be considered are the Veteran's right and left lower extremity radiculopathy, each rated as 10 percent disabling from April 5, 2013 and 20 percent disabling from March 21, 2016. These are rated under sciatic nerve impairment criteria found in 38 C.F.R. § 4.124s. Under Diagnostic Code 8520, a 10 percent rating is warranted for mild incomplete paralysis of either sciatic nerve. A 20 percent rating is warranted for moderate incomplete paralysis. A 40 percent rating is warranted for moderately severe incomplete paralysis. A 60 percent rating requires severe incomplete paralysis, with marked muscular atrophy. Terms such as "mild," "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6. The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the typical picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. 38 C.F.R. § 4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The Veteran had no radicular signs on VA examination in November 2011. Accordingly, a compensable rating for right or left lower extremity radiculopathy is not permitted based on this examination. However, on September 28, 2012, the Veteran reported leg pain; Achilles reflex could not be elicited and strength was 4/5 and he was assessed with sciatic leg pain and tingling in his extremities. A 10 percent rating for each lower extremity under Diagnostic Code 8520, for mild incomplete paralysis of the sciatic nerve, is warranted from this date. The Board will award this level of compensation through October 2, 2014, as the evidence shows this level of impairment throughout this period. Records during this period demonstrate sensory complaints, at times intermittent, with generally normal, or close to normal, strength and reflexes. Moderate incomplete paralysis was not shown during this time period, as reflected by a number of symptoms that were normal or almost normal during this time period, without significant prolonged or more serious symptomatology. The Board next concludes that from October 3, 2014, a 20 percent rating, but no higher is warranted for each lower extremity's lumbar radiculopathy. As of that date, the record reflects intermittent positive findings with respect to both motor strength and reflexes. The Board does not find that moderately severe or severe incomplete paralysis of either sciatic nerve is not shown. A higher rating is not warranted as, for example, calf circumference was equal bilaterally in July 2015 and the May 2016 VA examination report shows no muscle atrophy. The 2016 VA examination also found normal muscle strength and reflexes, and sensation intact in the lower extremities bilaterally. The only symptoms were sensory, ranging from mild to severe in each lower extremity. The regulations require wholly sensory involvement to be at most a moderate rating under this diagnostic code. No other associated neurological abnormalities are claimed or shown, and so no other ratings based on associated neurological abnormalities are warranted. Other considerations The Board has considered any and all lay statements from the Veteran as well as all rating criteria. The preponderance of the evidence is against greater benefits for lumbar spine disability than those indicated herein and there is no doubt to be resolved. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1991). The Board must address whether referral for extra-schedular consideration is warranted under 38 C.F.R. § 3.321(b)(1), either for the individual disability on appeal or for the combined effects of multiple service-connected disabilities, "only when that issue is argued by the claimant or reasonably raised by the record." Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). If extra-schedular consideration is raised, then the Board must undertake the three-part Thun test for referral. Id. "The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate." Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). First, there must be "a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability." Id. "[I]f the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required." Id. Second, "if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as ... 'marked interference with employment' and 'frequent periods of hospitalization.'" Id. at 115-16 (quoting § 3.321(b)(1)). Finally, if the first two steps are satisfied, then the third step is referral of the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for "a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating." Id. at 116. The Court in Yancy stated, "Essentially, the first Thun element compares a claimant's symptoms to the rating criteria, while the second addresses the resulting effects of those symptoms." Yancy, 27 Vet. App. at 494. The Court further stated that "the first and second Thun elements, although interrelated, involve separate and distinct analyses"; that "an error with respect to one element does not necessarily affect the Board's analysis of the other element"; and that "[i]f either element is not met, then referral for extra-schedular consideration is not appropriate." Id. at 494-95. This discussion applied to an analysis as to referral for extra-schedular consideration where there is only one service-connected disability. Id. at 495. The discussions above reflect that the rating criteria reasonably describe and contemplate the severity and symptomatology of the Veteran's service-connected back disability. The Board acknowledges that the March 2016 VA examination noted that the Veteran used a brace and a cane and had difficulty with sitting, standing and walking. The Board further acknowledges that the need to use an assistive device as a result of his back disability is not specifically enumerated by the rating criteria. Likewise, difficulty sitting, standing and/or walking are also not specifically enumerated in the schedular rating criteria. The Board does not disagree that cane use and walking or sitting problems are not listed in the schedular rating criteria. However, these unfortunate realities do not render the Veteran's service connected disabilities unique or unusual, and they do not mean that the schedular rating criteria do not adequately describe the symptoms of the Veteran's service connected disabilities, so as to trigger referral for extraschedular consideration. First, the use of a cane would be expected if a person was experiencing significant pain in the back. That is, it is not a unique or unusual result of a back disabilities. It may signal that a disability is more severe when a person requires the use of a cane, but the use of the cane is required because the symptoms of the disability have increased. This conclusion brings us to the second point that the use of an assistive device or cane is not a "symptom" of the Veteran's back disability; rather, it is the result of back symptoms such as pain. In other words, the Veteran uses a cane because of pain in his back, but pain is a symptom that is specifically contemplated by the schedular rating criteria. The same is true with limitations as to walking, sitting, or standing. The Veteran has difficulty standing and walking because of an increase in pain. Here, there are higher schedular ratings that would take into account increased pain. As such, even though the Veteran does use a cane, and has trouble with walking, standing and sitting, the schedular rating criteria reasonably describe his symptomatology. The symptoms and impairment caused by the service-connected low back disability are specifically contemplated by the schedular rating criteria including 38 C.F.R. §§ 4.40, 4.45. These include impairment caused by pain, limitation of motion, weakness, and other related factors. The symptoms and impairment caused by the Veteran's neurogenic bladder and bowel and right and left lower extremity radiculopathy are contemplated by 38 C.F.R. §§ 4.119, 4.114, 4.115a, and 4.124a, respectively. The neurogenic bladder is rated at the 60 percent schedular maximum from August 23, 2013. No other symptoms are claimed or shown. Thus, as the first Thun element is not met, referral for extraschedular rating is unnecessary. With regard to the Veteran's service-connected disabilities other than those related to his back, there is no argument or indication that they have any impact on the disability picture for his back disability on appeal. Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). "[A]lthough Johnson requires the Board, in certain cases, to discuss the collective impact of a claimant's service-connected disabilities, it does not alter the Board's jurisdiction over individual schedular or extra-schedular ratings." Yancy v. McDonald, 27 Vet. App. 494, 495. "Although the Board must consider any combined effects resulting from all of a claimant's service-connected disabilities insofar as they impact the disability picture of the disabilities on appeal, it lacks jurisdiction to consider whether referral is warranted solely for any disability or combination of disabilities not in appellate status...." Id. at 496 (emphasis in original). Thus, the Board does not have jurisdiction to consider referral for extra-schedular consideration based on the combined negative effects of the other disabilities. The Board has also considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) has been raised. Rice v. Shinseki, 22 Vet. App.447 (2009). Entitlement to TDIU is raised where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). Here, the evidence as late as October 2016 (VA DBQ) shows that the Veteran works full time for a government agency as a briefer. There is no evidence of unemployability due to the disabilities at issue. Further consideration of TDIU is not warranted. ORDER The claim for service connection for pseudofolliculitis barbae is reopened based on new and material evidence. However, service connection for pseudofolliculitis barbae is denied. A rating in excess of 20 percent for thoracolumbar spine limitation of motion prior to June 7, 2013 or from May 16, 2014 is denied. A 40 percent rating, but not higher, is granted for thoracolumbar spine limitation of motion from June 7, 2013 to May 15, 2014, subject to the controlling regulations applicable to the payment of monetary benefits. A rating in excess of 60 percent for neurogenic bladder is denied. A rating in excess of 60 percent for incontinence of bowel is denied. Ten percent ratings, but not higher, are granted for right and left lower extremity radiculopathy from September 28, 2012 to October 2, 2014, subject to the controlling regulations applicable to the payment of monetary benefits. A 20 percent rating, but no higher, is warranted from October 3, 2014 for right or left lower extremity radiculopathy, subject to the controlling regulations applicable to the payment of monetary benefits. REMAND On service entrance examination in August 1973, the Veteran reported that he had or had had sinusitis. However, clinically, his sinuses were normal at that time. A January 1994 service examination was normal. In November 1994, the Veteran denied having or having had sinusitis. On service discharge examination in March 1996, he reported sinus headaches in winter. Clinically, his sinuses were normal. The claim for service connection for sinusitis was filed in January 2011, with the Veteran stating at that time that all relevant medical records were in his service medical records. Since that time, VA treatment records have been associated with the claims file which include an April 2013 record which notes chronic sinus congestion; a December 2013 record which prescribes Flunisolide Nasal Spray for treatment of allergic rhinosinusitis; 2013 and 2016 sleep medicine assessments which note sinus problems affecting the use of the AutoPAP; and an August 2016 record which notes sinus congestion. The Veteran has not been provided with a VA examination with respect to any of his respiratory complaints, to include sinusitis and rhinosinusitis. Generally, a VA medical examination is required for a service connection claim when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in-service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low for the purposes of providing a medical examination. Id. The standards of McLendon are met in this case. The law provides relevant evidence must be considered in the first instance by the RO unless the claimant waives initial RO consideration of it, unless the substantive appeal was received on February 2, 2013 or later. The Veteran's VA Form 9 substantive appeal for his appeal for a higher rating for gastroesophageal reflux disease was received in March 2012. The most recent supplemental statement of the case concerning this issue was issued in January 2015. Thereafter, additional relevant evidence was received on appeal concerning this issue. For instance, there was a VA examination for gastroesophageal reflux disease in May 2016. In November 2016, the Veteran indicated that he wanted it reviewed by the RO in the first instance. Accordingly, the case is REMANDED for the following action: 1. Obtain all updated VA and non-VA treatment with respect to the claims remaining on appeal. 2. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of any current respiratory disability(ies), to include sinusitis and rhinosinusitis. The claims file must be reviewed in connection with the examination. The examiner is asked to identify all diagnosable respiratory disabilities. For each diagnosed respiratory disability, and to include rhinosinusitis, the examiner should opine whether it is at least as likely as not (50 percent or higher degree of probability) that it began in service, is caused by service, or is otherwise related to service. In rendering the requested opinions, the examiner should specifically address the service treatment records noting the Veteran complained of sinus headaches. A complete rationale for all opinions must be provided. 3. Consider in the first instance all evidence concerning the Veteran's claim for an increased rating for gastroesophageal reflux disease which has been received since the January 2015 supplemental statement of the case. 4. Thereafter, if any benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Following this, the case should be returned to the Board in accordance with the usual appellate procedures, if necessary. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim 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). _____________________________________ M. C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs