Citation Nr: 18154245 Decision Date: 11/29/18 Archive Date: 11/29/18 DOCKET NO. 16-49 795 DATE: November 29, 2018 REMANDED Entitlement to service connection for a right upper extremity neurological disability (claimed as permanent nerve damage in right arm), including secondary to a service-connected cervical spine disorder, is remanded. REASONS FOR REMAND The Veteran had active duty service from March 1969 to March 1971. Whereas the statement of the issue on appeal originally was entitlement to service connection for permanent nerve damage in the right arm, the Board has construed the issue more broadly as to include any right arm neurological disorder that is demonstrated. 1. Entitlement to service connection for a right upper extremity neurological disability (claimed as permanent nerve damage in right arm), including secondary to a service-connected cervical spine disorder is remanded. For purposes of the present claim, there was a November 2016 VA examination which found no neurological disorder, radiculopathy or general issue with the right upper extremity (RUE), and considered any symptomatology or pathology shown to have been from a right shoulder surgery and recent rotator cuff tear. The Board however observes that as recently as February 2013, the VA examination then of the cervical spine clearly notated RUE pain and paresthesias involving the thumb, index and middle fingers. There was medical history of radiating pain, and other neurological right arm symptoms. Accordingly, there is prior history of claimed disability, not all of it remote. See generally, McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (holding that evidence of disability preceding the date of claim should also be considered with regard to its probative value towards whether a disability existed at the date of filing of the claim). The case should therefore be remanded for re-examination by a neurologist to definitively address whether there is a current disability or whether one was present during the appeal period. The designated examiner is requested to further consider, in addition to the medical history, the specific claimed mechanism of injury that the Veteran experienced a fall during service, subsequently a ruptured cervical spine disc, and that over the next several years and various remedial procedures the consisted persisted somewhat, having reappeared more lately. There are further indicated several sources of private treatment records with regard to the neurological condition claimed, insofar as the Veteran has described instances of treatment following initial injury during the 1970s. The matter is REMANDED for the following action: 1. Contact the Veteran and request that he complete a medical authorization form (VA Form 21-4142) identifying all additional sources of private medical treatment for his claimed right arm neurological disorder, specifically that from a Dr. Lombardi, with the employer clinic at Goodyear, Inc. from during the 1970s onward (taking for purposes of the claim being reasonable likelihood that said records are still available). 2. Schedule the Veteran for an examination with an appropriate clinician. The claims file must be provided to and reviewed by the examiner in conjunction with the examination. Initial examination should determine whether the Veteran has the condition of any current right arm disability comprised of neurological impairment. The examiner should then provide an opinion regarding whether the disorder at least as likely as not (50 percent or greater probability) was incurred during military service, based upon an averred in-service fall injury and the theory stated that the resulting cervical disc injury caused nerve impingement thereby affecting the right upper extremity region. Although an independent review of the claims file is required, the examiner’s attention is drawn to the various stages of the pertinent medical history including –– neck remedial surgical procedures in 1974, 1977, and 1983; then treatment at St. Francis Hospital in 1985 with spontaneous increase in neck, shoulder and arm pain; then notation at his February 2013 VA examination that the Veteran was continuing to have pain at the cervical spine and right upper extremity pain / paresthesias involving the thumb, index and middle fingers. The examiner’s attention is additionally drawn to the November 2016 Peripheral Nerves Conditions examination. Then the examiner is requested to further determine whether the claimed right arm disability is secondarily related to service-connected cervical spine degenerative arthritis by providing opinions as to the following: a. Whether it is as least as likely ast not that the Veteran’s right arm neurological disability was proximately due to or the result of the cervical spine disorder; or, b. Whether it is at least as likely as not that it was aggravated by the cervical spine disorder. The examination report should include an explanation for all opinions stated. If the examiner cannot respond to the inquiries posed without resort to speculation, he or she should further explain why. 3. Then, readjudicate the claim. If any decision is unfavorable to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jason A. Lyons, Counsel