Citation Nr: 18152890 Decision Date: 11/27/18 Archive Date: 11/26/18 DOCKET NO. 08-20 306 DATE: November 27, 2018 REMANDED Entitlement to service connection for a bilateral shoulder disability is remanded. Entitlement to service connection for a cervical spine disability is remanded. REASONS FOR REMAND The Veteran had active duty service from May 1979 to August 1992. The Veteran is seeking service connection for a bilateral shoulder disability and a neck disability. Specifically, the Veteran contends that she injured her shoulders and neck in 1984, while on guard duty in service, as a result of wearing a radio backpack for an extended period of time. Alternatively, the Veteran contends that her bilateral shoulder and cervical disabilities are caused by her service-connected lumbar spine disability. Of evidence are translated German medical records which show the Veteran received treatment in February 1984 and was diagnosed with “backpack paralysis” affecting the thoracic longus nerve. It was also noted that she sustained “complete denervation in serratus anterior muscle…in the upper arm that are supplied by the plexus.” Several VA examinations and opinions have been obtained to determine the etiology of the Veteran’s bilateral shoulder and cervical spine disabilities; however, these examinations were deemed inadequate in the Board’s prior remands. Similarly, the Board finds the May 2016 and June 2016 VA examination and opinions inadequate for failure to comply with the Board’s June 2014 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). After further review of the Veteran’s claims file, the Board notes that the evidence seems to suggest that the Veteran’s bilateral shoulder and neck disabilities may be proximately due to her service-connected long thoracic nerve injury. Medical literature shows that the long thoracic nerve “originates from the C5–C7 roots and descends in the axilla, posterior to the brachial plexus, to innervate the serratus anterior muscle, which anchors the scapula to the chest wall.” “Injuries to the long thoracic nerve cause winging of the scapula, especially with the arm in anterior abduction.” See https://www.sciencedirect.com/topics/neuroscience/long-thoracic-nerve. Notably, the Veteran had anterior cervical diskectomy and fusion at the C5-C6 and C6-C7 levels in June 2007. In addition, the examiner in the Veteran’s November 2005 VA neurological examination found that the Veteran’s long thoracic nerve paralysis produced a mild amount of pain around the right shoulder area. In her January 2007 VA examination for muscles, the examiner found that the Veteran has a serratus anterior muscle injury as a residual to peripheral nerve damage of the long thoracic nerve that enervates the muscle, and that the two conditions cannot be separated. Further, a February 2009 neurology note shows that the Veteran sustained a brachial plexus injury due to carrying a radio pack in service. Given that none of the examinations of record have adequately addressed whether the Veteran’s bilateral shoulder and neck disabilities are proximately due to the Veteran’s service-connected thoracic nerve disability, a new examination and opinions are warranted. Additionally, as noted above, the most recent examinations failed to comply with prior Board remand directives; therefore, new examinations are warranted. On remand, the examiner must consider all diagnosed cervical and shoulder disabilities, to include reports of pain, in the rendered opinion. See Saunders v. Wilkie, 2018 U.S. App. LEXIS 8467 (Fed. Cir. Apr. 3, 2018). Further, consideration should be given to the Veteran’s lay statements, to include her contention that she aggravated her neck and bilateral shoulder conditions with continued use of the backpack as she was unaware of the German physician’s advice to discontinue using a backpack until the medical documents were translated in 2005. Accordingly, the matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate them with the claims file. 2. Obtain a medical opinion from a neurologist, if a neurologist is unavailable, obtain a medical opinion from an otherwise qualified physician to determine the etiology of the Veteran’s cervical spine and bilateral shoulder disabilities which appear to involve the nerves. Afford the Veteran a VA examination only if deemed necessary by the examiner. The claims file must be made available to, and thoroughly reviewed by the examiner. The examiner should note in the opinion that the file was reviewed. The physician should first identify all currently diagnosed cervical spine disabilities and bilateral shoulder disabilities provide an opinion as to the following: a) The examiner should identify any currently diagnosed cervical spine disabilities and right or left shoulder disabilities. If the Veteran does not have a right or left shoulder disability, the examiner must opine whether the Veteran has right or left shoulder pain resulting in functional impairment. b) For each disability listed above, or if no disability is diagnosed, for any pain with functional impairment, is it at least as likely as not (50 percent probability or greater) that such disability or pain was caused by service, to include as due to carrying a radio backpack in service? c) The examiner should also opine whether any identified cervical spine disability or shoulder disability, or for any shoulder pain with functional impairment, is at least as likely as not (50 percent probability or greater) proximately due to, or caused by, the Veteran’s service-connected thoracic nerve disability and/or the Veteran’s service-connected lumbar spine disability? d) A clear explanation for all opinions based on specific facts for the case as well as relevant medical principles is needed. If the examiner(s) determine that he or she is unable to provide the requested opinion without resort to speculation, the examiner(s) must provide a reasoned explanation for such conclusion. 3. The AOJ should review the examination reports to ensure that they are in compliance with this remand. If the reports are deficient in any manner, the AOJ should implement corrective procedures. (Continued on the next page)   4. After completion of the above, readjudicate the claims. If any benefit requested on appeal is not granted to the Veteran’s satisfaction, the Veteran and her representative should be furnished a supplemental statement of the case and provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if in order. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Laffitte, Associate Counsel