Citation Nr: 1817129 Decision Date: 03/19/18 Archive Date: 03/30/18 DOCKET NO. 12-00 361 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent prior to September 19, 2017 and in excess of 20 percent beginning September 19, 2017 for left carpal tunnel syndrome. 2. Entitlement to an initial rating in excess of 10 percent prior to September 19, 2017 and in excess of 30 percent beginning September 19, 2017 for right carpal tunnel syndrome. 3. Entitlement to a rating in excess of 10 percent for spinal stenosis with degenerative disease, to include intervertebral disc syndrome (IVDS). 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Adam Neidenberg, Attorney WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD N. Breitbach, Associate Counsel INTRODUCTION The Veteran served on active duty with the United States Air Force from March 1990 to April 1997. These matters are before the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In June 2015, the Veteran appeared at a Board hearing before a Veterans Law Judge who is no longer employed by the Board. A transcript of the hearing is of record. In January 2018, the Board notified the Veteran of the opportunity for him to appear at a new hearing before the Board. Correspondence from the Veteran's attorney received in February 2018 states the Veteran did not wish to appear at an additional Board hearing. This case was previously before the Board in March 2016 when it was remanded for further action. A November 2017 rating decision increased the rating for right carpal tunnel syndrome to 30 percent, effective September 19, 2017 and the rating for left carpal tunnel syndrome to 20 percent, effective September 19, 2017. The Veteran has not expressed satisfaction with these ratings, and they are less than the maximum under the applicable criteria; hence, the claim remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's left carpal tunnel syndrome has been manifested by moderate incomplete paralysis. 2. Throughout the appeal period, the Veteran's right carpal tunnel syndrome has been manifested by moderate incomplete paralysis. 3. Throughout the appeal period, the Veteran's spinal stenosis with degenerative disease has been manifested by forward flexion greater than 30 degrees but not greater than 60 degrees and combined range of the thoracolumbar spine not greater than 120 degrees, when considering pain and associated functional loss; with IVDS but with no incapacitating episodes. 4. The Veteran's service-connected disabilities preclude him from securing and maintaining substantially gainful employment consistent with his education and occupational experience. CONCLUSIONS OF LAW 1. Throughout the appeal period, the criteria for a 20 percent, but no higher, initial rating for the Veteran's service-connected left carpal tunnel syndrome are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.10, 4.120, 4.124a, Diagnostic Code 8515 (2017). 2. Throughout the appeal period, the criteria for a 30 percent, but no higher, initial rating for the Veteran's service-connected right carpal tunnel syndrome are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.10, 4.120, 4.124a, Diagnostic Code 8515 (2017). 3. Throughout the appeal period, the criteria for a 20 percent, but no higher, rating for the Veteran's service-connected spinal stenosis with degenerative disease, to include IVDS, are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.10, 4.71a, Diagnostic Code 5243 (2017). 4. The criteria for entitlement to a TDIU are met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017). Neither the Veteran nor his attorney has raised any issues with the duty to notify. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board"). In a December 2015 brief, the Veteran's attorney requested a separate compensable rating for the Veteran's radicular symptoms and requested a VA examination with a nerve conduction study. The Veteran was afforded an additional VA examination in September 2017 where his radicular symptoms were evaluated. A nerve conduction study was not performed, but the VA examination illustrated the Veteran had no signs or symptoms of radiculopathy in the lower extremities. Therefore, an additional VA examination or electromyography testing are not warranted. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-83 (2007); VAOPGCPREC 11-95 (1995). The Veteran's attorney has not raised any other issues with the duty to assist. Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Legal Criteria and Analysis Initially, the Board notes that it has reviewed all of the evidence in the Veteran's record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (noting that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence, as deemed appropriate, and the Board's analysis will focus specifically on what the evidence shows, or does not show, as to the claims. This decision will address the issues before the Board in turn. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. See 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. See 38 C.F.R. § 4.40. Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. See 38 C.F.R. § 4.45. The Veteran is right handed, so his right upper extremity is considered the major upper extremity. 38 C.F.R. § 4.69. His left upper extremity is considered the minor upper extremity. Id. Carpal Tunnel Syndrome The RO rated the Veteran's service-connected left carpal tunnel syndrome at 10 percent prior to September 19, 2017 and at 20 percent beginning September 19, 2017 under Diagnostic Code 8515. 38 C.F.R. § 4.124a. The RO rated the Veteran's service-connected right carpal tunnel syndrome at 10 percent prior to September 19, 2017 and at 30 percent beginning September 19, 2017 under Diagnostic Code 8515. 38 C.F.R. § 4.124a. For the major extremity, Diagnostic Code 8515 provides a 10 percent rating for mild incomplete paralysis, a 30 percent rating for moderate incomplete paralysis, and a 50 percent rating for severe incomplete paralysis. A 70 percent rating is assigned where there is complete paralysis of the major extremity. For the minor extremity, Diagnostic Code 8515 provides a 10 percent rating for mild incomplete paralysis, a 20 percent rating for moderate incomplete paralysis, and a 40 percent rating for severe incomplete paralysis. A 60 percent rating is assigned where there is complete paralysis of the minor extremity. 38 C.F.R. § 4.124a. The rating code provides that the term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. See Miller v. Shulkin, 28 Vet. App. 376 (2017) (finding that the plain language of the note to § 4.124a contains no mention of non-sensory manifestations and declining to read into the regulation a corresponding minimum disability rating for non-sensory manifestations). The words "mild," "moderate," 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 degree that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of descriptive terminology such as "mild" by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 U.S.C. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. Following an extensive review of the record, the Board finds that the evidence more nearly approximates an assignment of a 20 percent rating for the left upper extremity and a 30 percent rating for the right upper extremity under Diagnostic Code 8615, but no higher, for the entire period on appeal. An October 2007 electromyography (EMG) showed evidence of bilateral moderate carpal tunnel syndrome. At an August 2009 VA examination of the upper extremities, the sensory examination revealed normal vibration and position sense bilaterally. However, the Veteran had reduced sensation bilaterally with the pinprick test and light touch test. The VA examiner noted that the nerve affected was the Veteran's median nerve. The Veteran had a positive Phalen's test bilaterally. The Veteran had normal strength in the upper extremities. The VA examiner noted that the Veteran's condition imposes problems with daily activities and had significant effects on his occupation, including weakness or fatigue, decreased strength, and pain. The Veteran reported that he wears wrist braces at night for his carpal tunnel syndrome and that he experiences paresthesias, manifested as tingling, and pain. The Veteran attended an additional VA examination in October 2011 where the VA examiner diagnosed the Veteran with bilateral moderate carpal tunnel syndrome. The Veteran reported that he experienced numbness and tingling in both hands and regularly experienced decreased grasp strength with prolonged holding of objects. The examiner opined that the Veteran should be able to maintain substantially gainful sedentary employment. The examiner reasoned in part that the Veteran's carpal tunnel syndrome had been stable. At a September 2017 VA examination, the examiner noted that the Veteran had moderate incomplete paralysis bilaterally of the median nerve. Further, Phalen's and Tinel's tests were positive bilaterally, the Veteran had reduced grip and pinch strength bilaterally at 4/5. Sensory examination revealed decreased sensation at the hand/fingers bilaterally. The examiner stated that the functional impact of the Veteran's bilateral carpal syndrome is that the condition impacts any job requiring prolonged or repetitive use of the hands such as computer, handwriting, carpentry, or driving. At the examination, the Veteran reported symptoms of persistent numbness, paresthesia and pain of both hands, weakness after performing prolonged hand manipulations, and that he frequently drops objects. Further, the Veteran reported moderate constant pain, intermittent pain, and numbness bilaterally while reporting mild paresthesia bilaterally. In addition, the Veteran reported regular use of a brace bilaterally for his carpal tunnel syndrome. The Board has considered the Veteran's statements throughout the appeal period and deems that they are consistent with a finding of moderate incomplete paralysis bilaterally. The Veteran reported in an October 2011 statement that it has been harder to write and grip due to his carpal tunnel syndrome. The Veteran reported at his June 2015 Board hearing that his wife has to tie his shoes. In addition, the Board has considered the Veteran's spouse's testimony at the June 2015 Board hearing that the Veteran cannot grasp and hold anything, that she has to tie the Veteran's shoes, the Veteran cannot do light folding of laundry since the laundry slides out of his hands, and he cannot do everyday chores around the house. The Veteran's godsister reported in a June 2015 statement that she has seen the Veteran struggle to tie his shoes and that he now does not wear shoes with laces. The Veteran's attorney contended at the June 2015 Board hearing that the Veteran's carpal tunnel syndrome is moderate under the rating schedule based on the 2007 EMG that showed bilateral moderate carpal tunnel syndrome and that the record does not show that the Veteran's condition has improved. The Board concludes the medical evidence and the consistent statements from the Veteran, his spouse, and godsister support the attorney's contention. Therefore, the Board finds that the evidence shows the Veteran's bilateral carpal tunnel syndrome is most nearly approximated by moderate incomplete paralysis of the upper extremities under Diagnostic Code 8515 for the entire appeal period. 38 U.S.C. § 5107(b). A preponderance of the evidence is against a finding that the Veteran's carpal tunnel syndrome more nearly approximates severe incomplete paralysis. Regarding whether referral for an extraschedular rating is appropriate, such has not been raised by the claimant or reasonably raised by the record and will not be further discussed herein. Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017). In sum, the criteria for a 20 percent, but no higher, rating for the left upper extremity and a 30 percent, but no higher, rating for the right upper extremity due to moderate incomplete paralysis under Diagnostic Code 8515 have been met for the entire appeal period. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Spine Disability The Veteran's spinal stenosis with degenerative disease is rated as 10 percent disabling throughout the appeal period under Diagnostic Code 5243. 38 C.F.R. § 4.71a. The Veteran's IVDS can be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. The General Rating Formula for Diseases and Injuries of the Spine provides that with or without symptoms such as pain, stiffness, or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply: A 10 percent rating is warranted where there is forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees; or, the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasms, guarding, or localized tenderness severe enough to result in an abnormal gait or abnormal spinal; or, vertebral fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted where there is forward flexion of the thoracolumbar spine 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; or, muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted when forward flexion of the thoracolumbar spine is 30 degrees or less; or, when there is favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code. Under the Formula for Rating IVDS, a 10 percent rating is warranted with incapacitating episodes having a total duration of at least 1 week but less than 2 weeks during the past 12 months. A 20 percent rating is warranted with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is warranted with incapacitating episodes having a total duration of at least 6 months. An incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Note (1) provides that for purposes of evaluating under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. For the reasons that follow, the Board finds that the evidence more nearly approximates an assignment of a 20 percent rating under Diagnostic Code 5243 for the Veteran's spine disability, but no higher, for the entire period on appeal. 38 C.F.R. § 4.71a. At an August 2009 VA examination, the Veteran had forward flexion to 80 degrees with pain, extension to 20 degrees with pain, left and right lateral flexion to 20 degrees with pain, and left and right lateral rotation to 20 degrees with pain. The Veteran was able to perform repetitive use testing without additional loss of range of motion. The examiner noted that the Veteran did not have ankylosis. The Veteran attended a VA examination in September 2017 for an evaluation of his spine disability. Upon range of motion testing, the Veteran had forward flexion to 70 degrees with pain, extension to 10 degrees with pain, left and right lateral flexion to 20 degrees with pain, and left and right lateral rotation to 20 degrees with pain. The examiner noted the Veteran had pain with functional loss on all planes tested. The Veteran was able to perform repetitive use testing without additional loss of range of motion. This range of motion testing warrants a 10 percent rating under the General Rating Formula; however, the Board finds that evidence more nearly approximates an assignment of a 20 percent rating based on the entirety of the record. The September 2017 VA examiner noted the Veteran had pain on weight bearing, the Veteran had tenderness over the mid lower lumbar area, and that the Veteran had muscle spasm that did not result in an abnormal gait. The examiner diagnosed the Veteran with degenerative arthritis of the lumbar spine with IVDS and spinal stenosis. The examiner diagnosed the Veteran with IVDS, but the examination report reflects that the Veteran has not had any period of prescribed bed rest in the preceding 12 months. The Veteran did not have ankylosis of the spine. The examiner stated the functional impact of the Veteran's condition is that the condition would impact any job requiring prolonged standing, lifting, or walking. The Veteran reported at the examination that he has recurrent lumbar pain that is aggravated by prolonged standing, walking, lifting, and use of stairs. The Veteran reported monthly flare-ups that occur after he pushes himself up and walks too long and that during flare-ups the pain gets very severe and he has to stay in bed the whole day. The findings made on September 2017 VA examination are consistent with the evidence throughout the appeal period. A May 2009 VA treatment record illustrates the Veteran had decreased range of motion in the lumbar spine at all planes. The treatment note does not provide exact range of motion numbers. In addition, the Veteran stated at his June 2015 Board hearing that he did physical therapy for his spine condition in 2012 or 2013 that initially helped improve his functioning but that has not persisted. The Veteran testified that after doing the exercises for a week that his pain level increases and then he has to wait about two weeks before doing the exercises again. Further, the Veteran testified that his back pain has been more debilitating in the last five years. The Board has considered the Veteran's spouse's testimony at the June 2015 Board hearing that the Veteran is unable to sit or stand for a long period because of his back, that the Veteran has to rock back and forth prior to getting out of bed, and that she has to assist the Veteran with showering. The Board has considered the June 2015 statements from the Veteran's godsister and godbrother who stated that they tried exercising by walking 10 minutes, but the Veteran was in pain to the point that he could not stand. In evaluating the Veteran's increased rating claim, the Board must address the provisions of 38 C.F.R. §§ 4.40 and 4.45. The Board recognizes the Veteran's complaints of pain, stiffness, and functional loss as a result of his spine disability, notably his difficulty with prolonged sitting, standing, and walking. When considering the reports of functional loss as shown by the VA examination, the Veteran's reports of pain and stiffness, and the lay statements from the Veteran's spouse and godsister and godbrother, the Board concludes the evidence most nearly approximates thoracolumbar spine forward flexion that was greater than 30 degrees, but not greater than 60 degrees throughout the appeal period. However, even when considering the reported functional loss, the Veteran's disability picture did not more nearly approximate forward flexion limited to 30 degrees or less or with favorable ankylosis of the entire thoracolumbar spine. Thus, a 20 percent rating, but no higher, is warranted throughout the period on appeal. The Board has considered whether the Veteran is entitled to a higher rating under the rating criteria for IVDS. However, the evidence does not show that the Veteran had any episode of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in any 12 month period beginning 12 months prior to the Veteran's increased rating claim and through the appeal period. The September 2017 VA examiner diagnosed the Veteran with IVDS. However, the VA examiner noted that the Veteran had not had any incapacitating episodes in the 12 months preceding the September 2017 examination. A review of the record illustrates there are no prescribed periods of bed rest at any point throughout the appeal period. Therefore, a rating in excess of 20 percent for the spine disability is not warranted under the rating criteria for IVDS. Finally, the Board also acknowledges that Note (1) to the General Rating Formula for Diseases and Injuries of the Spine provide for separate rating(s) for associated neurologic impairment, including bowel or bladder impairment. The Veteran is separately rated for carpal tunnel syndrome of the upper extremities and the evaluations of those disabilities are discussed above. The record does not reflect that the Veteran has any bowel or bladder impairment; therefore, there is no basis for a separate award for neurological impairment on that basis. However, the Veteran's attorney contended at the June 2015 Board hearing and again in a December 2015 brief that the evidence warrants a separate compensable rating for radicular symptoms in the lower extremities. The Board acknowledges the Veteran's reports of radiating pain to the bilateral lower extremities throughout the appeal period, including in private treatment records, VA treatment records, and at the June 2015 Board hearing. Additionally, the Board recognizes VA treatment records from 2008, including one in December 2008, that indicate the Veteran had sciatica. However, physical examinations throughout the appeal period do not provide support for the subjective complaints of radiating pain and do not otherwise show diagnoses of sciatica or radiculopathy. The sensory examinations of the lower extremities at the August 2009 and September 2017 VA examinations were normal. Further, the Veteran had normal strength and normal reflexes at both examinations. At the September 2017 examination, the Veteran had a negative straight leg raising test bilaterally, and the examiner specifically found the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. Therefore, a preponderance of the evidence is against a finding that the Veteran has a neurologic impairment in the lower extremities. Regarding whether referral for an extraschedular rating is appropriate, such has not been raised by the claimant or reasonably raised by the record and will not be further discussed herein. Doucette, 28 Vet. App. at 369-70. In sum, the Board finds that the evidence most nearly approximates an assignment of a 20 percent rating, but no higher, for the entire period. Consequently, the benefit-of-the-doubt rule is not applicable. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. at 55. TDIU The Veteran seeks entitlement to a TDIU as he contends he is unemployable due to his service-connected disabilities. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). If there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16(a). For the above purpose of one 60 percent disability or one 40 percent disability in combination, disabilities resulting from common etiology or from a single accident are considered to be one disability. Id. The established policy of VA reflects that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). Factors such as employment history and educational and vocational attainments are to be considered. Id. For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The word "substantially" suggests an intent to impart flexibility into a determination of overall employability, as opposed to requiring the appellant to prove that he is 100 percent unemployable. Roberson v. Principi, 251 F.3d 1378, In this case, the Veteran has the following compensable service-connected disabilities: sleep apnea, rated at 50 percent; right carpal tunnel syndrome, rated at 30 percent; left carpal tunnel syndrome, rated at 20 percent; spinal stenosis with degenerative disc disease, now rated at 20 percent; and fracture of the left little finger and ganglion cyst removal on the left wrist, both rated as noncompensable. Thus, he meets the schedular criteria for entitlement to TDIU. The remaining (and dispositive) question is whether the service-connected disabilities render the Veteran incapable of participating in a regular substantially gainful occupation consistent with his education and work experience. Here, a balance of the evidence supports that the Veteran's service-connected disabilities substantially impact his ability to secure and engage in types of employment at any exertional level. The Veteran's September 2009 TDIU claim reflects that he completed his associate's degree in special education and took some social work classes. On the TDIU claim form, the Veteran reported working from October 1999 to October 2007 as a substitute teacher, courier, receiving clerk, and order picker. The Veteran reported he became too disabled to work in May 2008. The Veteran reported at the August 2009 VA examination that he was unemployed for less than one year and gave "laid off" as the reason for the unemployment. However, in a private vocational assessment of the Veteran in October 2015 based on a review of his record, J.S., concluded that the Veteran has not been able to perform any substantial gainful occupation since 2009 based on his service-connected disabilities. The Board affords great probative weight to this opinion as J.S. provided a detailed discussion of the Veteran's employment history and medical history. The ultimate question of whether a Veteran is capable of securing or following substantially gainful employment is an adjudicatory determination, not a medical one. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376 (2013). Based on the foregoing, the Board finds that the overall evidence of record shows the Veteran would have difficulty with most occupations due to his service-connected disability symptoms. Therefore, the Board concludes the Veteran is unable to secure or follow a substantially gainful occupation due to his service-connected disabilities. The Board finds that entitlement to a TDIU is warranted. ORDER Entitlement to a 20 percent, but no higher, initial rating throughout the appeal period for left carpal tunnel syndrome, is granted, subject to the regulations governing the payment of monetary awards. Entitlement to a 30 percent, but no higher, initial rating throughout the appeal period for right carpal tunnel syndrome, is granted, subject to the regulations governing the payment of monetary awards. Entitlement to a 20 percent, but no higher, rating throughout the appeal period for spinal stenosis with degenerative disease, to include IVDS, is granted, subject to the regulations governing the payment of monetary awards. Entitlement to a TDIU is granted, subject to the regulations governing payment of monetary awards. ____________________________________________ M. Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs