Citation Nr: 18150952 Decision Date: 11/19/18 Archive Date: 11/16/18 DOCKET NO. 09-00 172A DATE: November 19, 2018 REMANDED Entitlement to service connection for right upper extremity peripheral neuropathy is remanded. Entitlement to service connection for left upper extremity peripheral neuropathy is remanded. Entitlement to service connection for right lower extremity peripheral neuropathy is remanded. Entitlement to service connection for left lower extremity peripheral neuropathy is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1967 to April 1969, to include nine months in Vietnam. He was awarded the Combat Infantryman Badge, Bronze Star Medal, and Purple Heart. These matters come before the Board of Veterans’ Appeals (Board) from an October 2007 RO decision. The appeal has been before the Board in August 2012, October 2014, March 2016, and September 2016 when it was remanded for further development. The Veteran seeks service connection for peripheral neuropathy affecting all extremities. Unfortunately, another remand is unavoidable as the Board finds it necessary to obtain an additional VA medical opinion to determine the nature and etiology of the claimed peripheral neuropathy of all his extremities. Of note, service connection is in effect for peroneal nerve injury residuals from a combat gunshot wound to the left foot. The questions at hand are whether the Veteran has additional nerve involvement in the lower and upper extremities, and if so, whether it is related to service, to include herbicide agent exposure or another currently service-connected disability. Additional nerve involvement could result in manifestations different from the peroneal nerve manifestations. During October 2008 VA examinations of the feet and spine, the Veteran had decreased vibration sense in the toes of both feet and decreased light touch sensation over the palms and tips of his fingers. There was also some decreased sensation in part of his thighs. Additionally, a September 2016 medical opinion stated that the neurologic deficits the Veteran demonstrated during the October 2008 VA examinations were consistent with bilateral upper and lower extremity peripheral neuropathy. However, in a June 2016 VA examination report, the examiner, a physician’s assistant, concluded that the Veteran did not have peripheral neuropathy in the lower extremities and did not address the upper extremities at all. As noted in the prior Board remand, the September 2016 medical opinion conflicts with the June 2016 medical opinion to the extent that the June 2016 medical opinion found no neuropathy in the lower extremities. As such, the Board found that the June 2016 VA medical opinion was inadequate for several reasons and remanded the claim for an additional VA examination, in part, to reconcile the conflicting medical opinions of record. Subsequently, the Veteran was afforded another VA examination in October 2017. During the examination, the Veteran reported past transient numbness in all four extremities, but also reported that the numbness had resolved without any residuals. The examiner, a physician, concluded that because the Veteran had been asymptomatic for 12 months or longer and because his peripheral neuropathy examination was normal, it was less likely than not that the Veteran had a current diagnosis of peripheral neuropathy in any extremity. The examiner did not discuss the conflicting medical opinions of record or discuss symptoms and physical findings reported in the record as requested by the Board. In its current form, the October 2017 VA medical opinion is also inadequate. First, in finding no evidence of peripheral neuropathy in any extremity, the examiner did not reconcile the earlier neurological symptoms shown in the record, and instead, offered only a conclusory opinion. Second, the examiner did not consider or discuss whether the Veteran had a diagnosis of peripheral neuropathy at any time during the entire appellate period, which began in August 2007. Despite the October 2017 VA examiner’s determination that the Veteran did not meet the criteria for a diagnosis for peripheral neuropathy of any extremity, the Veteran has had potentially relevant symptoms during the appellate period and the cause of these symptoms must be obtained, even if the symptoms have now resolved. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Board is obligated by law to ensure that its remand directives have been substantially completed. When there is not substantial compliance, the Board errs as a matter of law when it fails to ensure that its directives are followed. Stegall v. West, 11 Vet. App. 268 (1998). As such, an addendum medical opinion should be obtained. The matters are REMANDED for the following action: 1. Obtain any outstanding pertinent VA treatment records and associate them with the claims file. 2. Then, obtain a VA addendum opinion from an appropriate clinician. Whether an additional physical examination is required is left to the discretion of the examiner. After a thorough review of the claims file, the examiner should address the following: (a). Identify any neurological disabilities in the upper and/or lower extremities at any time since the filing of this claim, excluding the service-connected left foot peroneal neuritis. (b). Specifically indicate whether the Veteran has had peripheral neuropathy or radiculopathy in each of the four extremities at any time since the filing of his claim in August 2007. Address and Reconcile the conflicting evidence of record. See October 2008 VA examination and the September 2016 positive VA medical opinion. (c). For each neurological disability present in each extremity since August 2007, provide an opinion as to whether it had its onset during active service, to include as due to presumed exposure to herbicide agents. (d) For each neurological disability identified for each extremity during the appellate period, provide an opinion as to whether it was (1) proximately caused by or (2) was aggravated by the service-connected gunshot wound to the left foot with peroneal neuritis. (e) For each neurological disability identified for each extremity during the appellate period, if any, provide an opinion as to whether it was (1) proximately caused by or (2) was aggravated by the service-connected lumbar spine disability. *In addressing these questions, attention is called to the October 2008 VA spine and foot examinations which document sensory deficits in all extremities and the June 2016, September 2016, and October 2017 VA medical opinions. *A complete rationale for each conclusion must be provided. 3. Readjudicate the claims on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Harper, Associate Counsel