Citation Nr: 18143568 Decision Date: 10/19/18 Archive Date: 10/19/18 DOCKET NO. 16-48 676 DATE: October 19, 2018 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD), with depression and anxiety, is granted. Entitlement to service connection for a neck condition is granted. Entitlement to service connection for a traumatic brain injury (TBI) is granted. FINDINGS OF FACT 1. The Veteran’s current PTSD is etiologically related to active service. 2. The evidence is in relative equipoise as to whether the Veteran’s current neck condition is etiologically related to active service. 3. The evidence is in relative equipoise as to whether the Veteran experienced a TBI related to active service. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD have been met. 38 U.S.C. §§ 1101, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 4.125. 2. Affording the Veteran the benefit of the doubt, the criteria for service connection for a neck condition have been met. 38 U.S.C. §§ 1101, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. Affording the Veteran the benefit of the doubt, the criteria for service connection for a TBI have been met. 38 U.S.C. §§ 1101, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1988 to January 1993. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a June 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. The Board notes that on the Veteran’s October 2016 VA Form 9, he specifically restricted his appeal to the issues of entitlement to service connection for PTSD, a neck condition, and a TBI. Thus, the issue of entitlement to a compensable disability rating for migraine headaches is not on appeal before the Board. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. §§ 1110, 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, 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 (Fed. Cir. 2004). Certain disabilities, including arthritis, organic neurological disorders, and psychoses, are presumed to be service connected if manifested to a compensable degree within one year following service. 38 C.F.R. §§ 3.303, 3.307, 3.309. Entitlement to service connection for PTSD Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., under the criteria of DSM-IV or DSM-5); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred (unless the evidence shows that the Veteran engaged in combat and the claimed stressor is related to combat). See 38 C.F.R. § 3.304(f). In this case, the Board acknowledges that in a May 2015 VA examination report, the Veteran was diagnosed with PTSD. In that examination report, the examiner found that it was less likely than not that the Veteran’s diagnosed PTSD was related to active service. However, in November 2017 and February 2018 VA examination reports, both examiners found that it was at least as likely as not that the Veteran’s PTSD was related to active service. In the November 2017 report, the examiner noted that “the Veteran experienced other criteria A events during military service but all his re-experiencing symptoms appear connected to [his stressor event].” In the February 2018 VA examination report, the examiner wrote that the Veteran’s psychiatric issues developed during and after service. The examiner noted that the Veteran underwent a severe head injury and was found to have a clear diagnosis of TBI, which produced and/or exacerbated the Veteran’s psychiatric and cognitive symptoms already developing as a result of his experiential trauma. Additionally, the Board notes that December 2015, February 2017, March 2017, November 2017, January 2018, and September 2018 letters from VA physicians all found a positive nexus between the Veteran’s PTSD and his traumatic experiences during active service. Accordingly, the criteria for service connection have been met, and the claim is granted. Entitlement to service connection for a neck condition In this case, the Board acknowledges that in an August 2016 VA examination report, the Veteran was diagnosed with cervical spondylosis. The Veteran reported that his neck problems began after being struck in the head by a tank hatch in 1990. During that examination, the examiner acknowledged that the Veteran’s range of motion could not be tested. The examiner opined that it was less likely than not that the Veteran’s neck condition was caused by or a result of active service. The rationale was that the Veteran’s medical records within two years of his discharge from service were silent for a neck condition. According to the VA examiner, there was no continuity of symptomatology in close proximity to the Veteran’s leaving active service. In an October 2017 Report of General Information, the Veteran asserted that the August 2016 examination only lasted five minutes and that the VA examiner only asked if the Veteran was in pain. The Veteran noted that he later received an eight-page examination report where the VA examiner stated that measurements were taken, but the Veteran denied this happened. In February 2017 and March 2017, the Veteran’s VA neurologist wrote a letter noting that the Veteran had been his patient since 2015. The VA neurologist reported that he had personally reviewed the Veteran’s medical history and had examined him numerous times. In the February 2017 letter, the VA neurologist wrote that an MRI taken in December 2014 showed mild spondylosis/degenerative disc disease (DDD). The clinical impression of the neurologists and pain specialists was that the Veteran had a cervicogenic component to his neck pain. In that letter, the VA neurologist opined that it was more likely than not that the Veteran’s cervicalgia was related to head trauma he experienced during active service. In the March 2017 letter, the VA neurologist wrote that the Veteran had chronic neck pain due to mild cervical spondylosis and DDD. The neurologist opined that it was more likely than not that the Veteran had neck pain related to his reported trauma while in active service. Weighing the available evidence, the Board finds that the February 2017 and March 2017 opinions from the Veteran’s VA neurologist, concluding that his neck pain was the result of trauma experienced during active service, combined with the competent and credible lay statements from the Veteran, are of at least equal probative value to the August 2016 VA examiner’s negative nexus opinion. The Board thus finds that it is at least as likely as not that the Veteran’s neck pain is etiologically related to active service. Accordingly, the criteria for service connection have been met, and the claim is granted. Entitlement to service connection for TBI In a May 2015 VA examination report, the examiner noted that the Veteran was not diagnosed with a TBI. In a subsequent June 2015 opinion, the VA examiner opined that the Veteran was not experiencing any residuals of a service-related head injury. In the examiner’s opinion, the Veteran’s multiple cognitive complaints were most likely the result of his psychiatric comorbidities. In a December 2017 VA examination report, the Veteran was diagnosed with a TBI. In that examination, the VA examiner found that it was at least as likely as not that the Veteran sustained a TBI during active service. The examiner noted that the Veteran was hit in the head with the hatch of a tank, was disoriented and could not recall the events immediately after, and started experiencing headaches. The VA examiner opined that it was at least as likely as not that the Veteran’s headaches were due to his TBI. In a February 2017 letter, the Veteran’s VA neurologist wrote that the Veteran had been his patient since February 2015. The neurologist noted that he had reviewed the Veteran’s medical records and had examined him multiple times. The VA neurologist noted that the Veteran experienced a head trauma in 1990 with a reported loss of consciousness of 30 to 60 minutes. A March 2015 MRI showed that the Veteran had a mild TBI with a structurally normal brain. Neuropsychological testing showed mild cognitive decline, but processing speed and executive functioning were severely affected. It was the VA neurologist’s opinion that it was more likely than not that the Veteran had a mild TBI related to his head trauma during active service. Weighing the available evidence, the Board finds that the December 2017 VA examination report and the February 2017 letter from the Veteran’s VA neurologist, concluding that the Veteran experienced a mild TBI during active service, combined with the competent and credible lay statements from the Veteran, are of at least equal probative value to the May 2015 VA examiner’s negative nexus opinion. The Board thus finds that it is at least as likely as not that the Veteran’s TBI is etiologically related to active service. Accordingly, the criteria for service connection have been met, and the claim is granted. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Abrams, Associate Counsel