Citation Nr: 1822366 Decision Date: 04/13/18 Archive Date: 04/25/18 DOCKET NO. 13-10 533 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include depression and anxiety. 2. Entitlement to service connection for erectile dysfunction. 3. Entitlement to service connection for a cervical spine disorder. 4. Entitlement to service connection for a left upper extremity nerve disorder. 5. Entitlement to service connection for a right upper extremity nerve disorder. 6. Entitlement to service connection for a left lower extremity nerve disorder. 7. Entitlement to service connection for a right lower extremity nerve disorder. (The issue of entitlement to service connection for a thyroid nodule and residuals of thyroidectomy is addressed in a separate decision under the same docket number.) REPRESENTATION Appellant represented by: Daniel G. Krasnegor, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Douglas, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from June 1982 to April 1986. The issues of entitlement to service connection for an acquired psychiatric disorder and for erectile dysfunction come before the Board of Veterans' Appeals (Board) by order of the United States Court of Appeals for Veterans Claims (hereinafter "the Court") in February 2016, which granted a joint motion for partial remand vacating that part of a May 2015 Board decision denying these issues and remanding them for additional development. These issues initially arose from an April 2014 rating decision by the Reno, Nevada, Regional Office (RO) of the Department of Veterans Affairs (VA). These issues were remanded for additional development in December 2016. In September 2014, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge. A copy of the transcript of that hearing is of record. The December 2016 remand also addressed the issues of entitlement to service connection for a lumbar spine disability and for tinnitus and that these issues were granted and the appeals fully resolved by an August 2017 rating decision. In granting service connection that determination combined lumbar degenerative disc disease, status post fusion with lumbar strain, with the previously established service-connected thoracic spine degenerative disc disease disability. The Board also notes that in March 2018 the Veteran submitted notice of disagreement with rating decisions in August 2017 and January 2018 as to the assigned thoracolumbar spine disability evaluation and the denial of entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). VA records these matters are under development, and, as such, no additional action is required at this time. The issue of entitlement to service connection for a thyroid nodule and residuals of thyroidectomy is addressed in a separate decision under the same docket number. The Veteran originally established a power of attorney agreement with the Disabled American Veterans. Since that time, he executed a power of attorney agreement with the above listed private attorney. The scope of that representation was specifically limited to the issues being decided in this decision, however. See VA Form 21-22a, dated September 2015 and March 2016. The issues of entitlement to service connection for cervical spine disorder and for left and right upper extremity nerve disorders are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. A chronic psychiatric disorder, to include depression and anxiety, was not manifest during active service or within one year of service; and, the preponderance of the evidence fails to establish that a present acquired psychiatric disorder is etiologically related to service. 2. Erectile dysfunction was not manifest during active service; and, the preponderance of the evidence fails to establish that a present erectile disorder is etiologically related to service or a service-connected disability. 3. A present left lower extremity (sciatic) nerve disorder is shown to be proximately due to a service-connected thoracolumbar spine disability. 4. A present right lower extremity (sciatic) nerve disorder is shown to be proximately due to a service-connected thoracolumbar spine disability. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder, to include depression and anxiety, have not been met. 38 U.S.C. §§ 1131, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 2. The criteria for service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1131, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.303, 3.310 (2017). 3. The criteria for service connection for a left lower extremity (sciatic) nerve disorder have been met. 38 U.S.C. § 1131 (2012); 38 C.F.R. §3.310 (2017). 4. The criteria for service connection for a right lower extremity (sciatic) nerve disorder have been met. 38 U.S.C. § 1131 (2012); 38 C.F.R. § 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The matter was Remanded in December 2016 for the purpose of securing updated VA treatment records, affording the Veteran a VA examination, and obtaining a medical opinion with respect to that examination. VA treatment records have been obtained and a VA examination was conducted in February 2017 with a corresponding report. The Board finds that there was substantial compliance with the December 2016 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 104-05 (2008). In a March 2018 brief in support of the claims, the Veteran asserted that a February 2017 VA opinion as to the psychiatric disability issue was inadequate. The Board finds no merit to this specific allegation. The February 2017 examiner is shown to have conducted a thorough review of the evidence and to have provided a substantially accurate summary of the evidence. The provided etiology opinions also clearly stated the present diagnoses were not "proximately due to in-service military experiences" and were most likely due to the combination of early childhood trauma and psychosocial issues in adulthood. The Board finds that the use of the phrase "proximately due to" to be a less restrictive standard than actual "onset" or "etiologically related to" service. The examiner is shown to have considered all of the available evidence and to have determined, in essence, that the criteria for a diagnosis before or during service were not met and that the post-service diagnosis had no proximate relationship to the evidence as to any incident of service. Overall, considering the entire report the provided opinions adequately addressed the December 2016 remand directives for an opinion addressing whether an acquired psychiatric disorder was either onset in service or was otherwise etiologically related to service. Neither the Veteran nor his attorney has raised any other issues with the duty to notify or duty to assist. 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."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Claims Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131 (2012). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; 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, 1166-67 (Fed. Cir. 2004). A Veteran is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service, or where clear and unmistakable evidence (obvious or manifest) establishes that an injury or disease existed prior to service and was not aggravated by service. 38 U.S.C. § 1111 (2012); 38 C.F.R. § 3.304(b) (2017). "Clear and unmistakable evidence" is an "onerous" evidentiary standard requiring that the conclusion be "undebatable." Cotant v. Principi, 17 Vet. App. 116 (2003) (citing Laposky v. Brown, 4 Vet. App. 331 (1993)). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during that active service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Aggravation may not be conceded where the disability underwent no increase in severity during service. 38 U.S.C. § 1153 (2012); 38 C.F.R. § 3.306 (2017). A lack of aggravation may be shown by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004); Horn v. Shinseki, 25 Vet. App. 231, 235 (2012). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a) (2017). When aggravation of a nonservice-connected condition is proximately due to or a result of a service-connected disability a veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Certain chronic diseases, including psychoses, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2017). Even though a disease is not included on the list of presumptive diseases, a nexus between the disease and service may nevertheless be established on the basis of direct service connection. Stefl v. Nicholson, 21 Vet. App. 120 (2007). When a claimed disability is not included as a presumptive disability, direct service connection may nevertheless be established by evidence demonstrating that the disability was in fact incurred during service. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). Psychoses and organic diseases of the nervous system are qualifying chronic diseases. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 3.102 (2017). Acquired Psychiatric Disorder The Veteran contends that he had an acquired psychiatric disorder as a result of active service. In statements and testimony in support of his claim he asserted, in essence, that he developed anxiety, depression, and/or a bipolar disorder due to events in service involving having been bullied or mistreated by others. Service treatment records are negative for complaint, treatment, or diagnosis of an acquired psychiatric disorder. In a September 1986 report of medical history the Veteran denied having or having ever had depression or excessive worry or nervous trouble of any sort. Private treatment records dated in November 2003 noted the Veteran had an approximately one year history of abusing cocaine and that he was becoming increasingly depressed over his drug usage. A November 2003 psychiatric examination noted he had a history of physical abuse from his father and sexual abuse from male cousins as a child. It was noted he admitted to a one year history of using crack cocaine and alcohol use since age 18 with occasional cocaine use. He reported having been depressed with significant situational stressors including finances. He stated he had been relocated from another state two years earlier by his employer of 15 years, but that he was facing bankruptcy because his family had been reduced to one income since the move. The examiner noted there was "no previous history of psychiatric treatment per se." A mental status evaluation revealed no evidence of overt psychotic symptomatology. Diagnoses of major depression and polysubstance abuse were provided. A February 2004 hospital report noted the Veteran was admitted with depression and suicidal ideation with a plan to overdose on drugs. An admission assessment noted his mood was depressed and that his thought content was nonpsychotic. Psychological testing was conducted and the diagnoses provided at discharge were major depression and polysubstance abuse/dependence. VA mental disorders examination in April 2012 included a diagnosis of recurrent major depressive disorder. It was noted that the Veteran stated his boot camp was an extremely difficult time for him and that he was held back, in part, because he was overweight and that he described a history of heavy alcohol use, cocaine, and marijuana use. The Veteran commented that he had been "self-medicating." He reported that it started when he got out of active service and then kept escalating. The examiner identified a sentinel event involving a February 1996 motor vehicle accident (MVA) in which his 9-year old niece was killed and noted the Veteran had not been driving. It was noted the Veteran reported he had been in a coma for three days, but that he denied any residual cognitive difficulties and stated he did not notice any effects from the MVA because he was "losing control before the accident" due to heavy drinking and bouts of severe depression. The examiner found the disorder was less likely proximately due to or the result of a service-connected condition. As rationale for the opinion it was noted the Veteran reported a lifelong history of low self-esteem, bullying, and symptoms of depression which likely pre-dated his military service. VA treatment records show treatment for depression and for bipolar disorder since 2009. A February 2014 report noted a review of the record revealed a diagnosis of unspecified bipolar disorder seemed to coincide with cocaine use. An October 2016 report noted the Veteran felt, generally, that his issues stemmed from his molestation as a child. VA examination in February 2017 included diagnoses of other specified bipolar and related disorder and recurrent major depressive disorder. The examiner noted the evidence of record was reviewed and reported a summary of the Veteran's relevant history including his having been sexually molested by a cousin at age 11 and having been physically and emotionally abused by his father. It was noted he described his childhood as difficult because he was trying to figure out his sexual identity after he was molested and growing up he was frequently bullied by his peers because he carried himself in a more "feminine" manner. He stated that he had continued being "bullied" by his noncommissioned officers and his peers and that he cried frequently and was isolated from his peers because he was overweight and unable to complete physical exercises. He stated that after boot camp he had been sent to Germany and housed in a room by himself because the other soldiers did not to room with him because of his sexuality. He reported that a fellow serviceman alleged the Veteran had sexually harassed him, but that the accusation was without merit and was summarily dismissed. He asserted he had experienced social alienation because others had spread false rumors. He reported he had improved relationships during his four years of military reserve service because he was only there once a month and that he had attained a noncommissioned officer rank. The examiner noted the Veteran believed he had been evaluated for a possible mental health issue in service because he had a "black out" and drove a truck into the motor pool in 1985, but that service treatment records were silent for any mental health treatment. It was noted he denied any arrests or adverse legal encounters while in service and reported a single incident with a roommate due to a "racial issue" early in his military career. He denied any problems with the physical expression of anger during service. He reported smoking cannabis while in the military and stationed in Germany in 1983. He reported he drank daily, but denied that his use of alcohol interfered in his ability to complete his work or impaired social relationships. The examiner noted that the Veteran indicated that his first long-term employment was with Ford Motor Company in Kansas City, Missouri, for approximately 20 years and that he had retired in 2007. He described his interactions at Ford Motor Company as "great" and that he achieved many recommendations and awards. He stated that after 10 years a manager had noted his dedication and he was offered a position to run a warehouse in California. He stated that the company paid for his college education and that he had a degree in business administration. He indicated that he left his position because of downsizing and the desire to test the market. In 2009, he was hired by the Department of Defense (DOD) as a "marketing manager and project manager" and while working with the DOD he obtained a Master's Degree in Project Management. He reported he left that position in November 2015 due to increasing physical and psychological problems. He stated that he was being harassed racially, sexually, and based upon age discrimination and reported that he won an Equal Opportunity lawsuit approximately three months earlier. He stated he felt that they had forced him to medically retire due to exacerbating pre-existing medical and mental health issues. The examiner found that the Veteran met the criteria for other specified bipolar and related disorder (hypomanic episodes with insufficient symptoms and major depression) that was less likely than not (less than 50 percent probability) proximately due to in-service military experiences. It was most likely that the other specified bipolar and related disorder was due to early childhood trauma (e.g., sexual molestation at age 11, physical and emotional abuse by father, gender identity), bullying throughout his lifetime, and ongoing substance use problems (e.g., alcohol, cocaine, and cannabis). A review of the literature concerning childhood trauma and bipolar disorder it was noted had shown that childhood traumatic events are associated with various severe clinical characteristics of bipolar disorder, including an earlier onset of the illness and higher number of lifetime mood episodes (citing Brown et al. 2005; Nemeroff, 2004; Weber et al. 2008). Additionally, there was a concern that the Veteran may have minimized his substance use history due to conflicting accounts of historical information from his primary therapist that indicated he was abusing cocaine and alcohol, noting that in excess amounts cocaine could have caused him to experience a substance-induced hypomanic episode. Furthermore, it was noted that the "APA (2013)" stated that in addition to challenging family situations, early childhood trauma individuals diagnosed with bipolar disorder may be partly caused by an underlying problem with specific brain circuits and the balance of brain chemicals called neurotransmitters. The examiner also found that the Veteran met the criteria for major depressive disorder that was less likely than not (less than 50 percent probability) proximately due to in-service military experiences. Instead, his psychiatric disorder was most likely due to a combination of early childhood trauma experiences (e.g., sexual molestation at age 11, substance use in adulthood, physical and emotional abuse by father, frequent bullying, feelings of hopelessness and/or worthlessness, and gender identity issues) and psychosocial issues in adulthood identified as ongoing difficulty with establishing and maintenance of gender identity, marital conflict, parent-child relationship, substance use (e.g., cocaine and alcohol), and occupational problems. Based upon the evidence of record, the Board finds that an acquired psychiatric disorder, to include depression and anxiety, was not manifest during active service. Evidence of a psychosis manifesting within one year of service is not demonstrated. There is no competent evidence of a diagnosis of an acquired psychiatric disorder for many years after service nor of any such diagnosis subsequently provided based upon symptoms shown by credible evidence to have been manifest during or as a result of active service. The preponderance of the evidence also fails to establish that a present acquired psychiatric disorder is etiologically related to service. The February 2017 VA opinion is persuasive and based upon adequate rationale. The examiner is shown to have reviewed of the evidence of record, including applicable medical literature, and to have adequately considered the credible lay statements and reported symptom manifestation history of record. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). There is no medical evidence to the contrary. In determining whether evidence submitted by a claimant is credible, VA may consider internal consistency, facial plausibility, and consistency with other evidence. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (superseded by statute for an unrelated point of law as stated by Duenas v. Principi, 18 Vet. App. 512 (2004)); see also Buchanan v. Nicholson, 451 F.3d at 1337 (VA can consider bias in lay evidence and conflicting statements of the veteran in weighing credibility). To the extent the Veteran contends that he had symptoms of an acquired psychiatric disorder during active service or such symptoms that subsequently developed after service as a result of events in service, the Board finds such matters are not credible due to inconsistency with the other evidence of record. The available service treatment records are negative for any in-service symptomatology and in a September 1986 report of medical history the Veteran denied having or having ever had depression or excessive worry or nervous trouble of any sort. Nor were any service-related symptoms or events identified upon private mental health evaluations in 2003 and 2004. Although at his April 2012 VA examination he reported having had bouts of severe depression prior to a February 1996 MVA, there is no competent evidence of treatment or a diagnosis of depression prior to 2003 nor any indication that subjective symptoms of depression prior to February 1996 were related to service. Consideration has also been given to the Veteran's personal assertion that he has a an acquired psychiatric disorder, to include depression and anxiety, related to his active service. However, while lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The disability at issue is not a condition that is readily amenable to lay diagnosis or probative comment regarding etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Board acknowledges that the Veteran is competent to report observable symptoms, such as depression, but there is no indication that he is competent to etiologically link any such symptoms to a current diagnosis. He is not shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that he received any special training or acquired any medical expertise in evaluating such disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, the lay evidence does not constitute competent medical evidence and lacks probative value. In conclusion, the Board finds that service connection for an acquired psychiatric disorder, to include depression and anxiety, is not warranted. When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). The preponderance of the evidence is against the claim. Erectile Dysfunction The Veteran contends that he has an erectile dysfunction as result of service, including as a result of medication for a service-connected disability. He has not asserted, nor does the evidence indicate, that an erectile dysfunction was manifest during service. Service treatment records are negative for complaint, treatment, or diagnosis of an erectile dysfunction. VA male reproductive examination in April 2012 included a diagnosis of erectile dysfunction. The examiner found the disorder was likely due to psychiatric medications and was less likely proximately due to or the result of service, including a lumbar spine disorder. It was noted the Veteran did not have urine or stool incontinence that would be present if his low back condition caused his erectile dysfunction. As rationale for the opinion it was noted that the medical literature revealed that antidepressant medications were associated with erectile dysfunction, but that the medications used to treat the Veteran's non-mental health conditions did not cause erectile dysfunction. An April 2017 VA medical opinion found a review of record revealed no evidence that the Veteran's present erectile dysfunction was aggravated by an acquired psychiatric disorder, including any in-service treatment for any such disorder. Based upon the evidence of record, the Board finds an erectile dysfunction was not manifest during active service, and that the preponderance of the evidence fails to establish that a present erectile disorder is etiologically related to service or a service-connected disability. The April 2012 VA opinion is persuasive and based upon adequate rationale. There is no medical evidence to the contrary and the lay evidence as to etiology lacks probative value. The preponderance of the evidence is against the claim. Lower Extremity Nerve Disorders The Veteran contends, in essence, that he has lower extremity nerve disorders as a result of service or a service-connected disability. Service treatment records are negative for complaint, treatment, or diagnosis of a lower extremity nerve disorder. VA records show service connection has been established for disabilities including thoracic and lumbar spine degenerative disc disease, status post fusion with lumbar strain. The pertinent medical evidence of record shows that VA examination in April 2012 provided diagnoses of thoracic and lumbar spine degenerative disc disease and found that the Veteran had moderate radiculopathy to the left lower extremity involving the sciatic nerve. The lower extremity neuropathy was found to be as likely as not due to lumbar spine degenerative disc disease. A November 2015 VA examination report provided diagnoses of lumbar spine degenerative disc disease and degenerative joint disease, parathoracic sprain, and musculotendinous strain of the lumbar spine. It was noted the Veteran had radiculopathy involving the left femoral and sciatic nerves. A February 2017 VA examination revealed radiculopathy with involvement to the sciatic nerves, bilaterally. A June 2017 VA back examination found no evidence of radiculopathy. VA examination in November 2017 included a diagnosis of thoracolumbar spine multilevel degenerative disc and joint disease with radiculopathy. The radiculopathy was found to involve the bilateral sciatic nerves and to be of moderate severity. Based upon the evidence of record, the Board finds that present left and right lower extremity (sciatic) nerve disorders are shown to be proximately due to the Veteran's service-connected thoracolumbar spine disability. The overall evidence is persuasive that he has bilateral lower extremity nerve disorders involving the sciatic nerves attributable to his thoracolumbar spine disability. The November 2015 finding as to left femoral nerve involvement is found to be inconsistent with the other evidence of record. Therefore, entitlement to service connection for left and right lower extremity (sciatic) nerve disorders is granted. ORDER Entitlement to service connection for an acquired psychiatric disorder, to include depression and anxiety, is denied. Entitlement to service connection for erectile dysfunction is denied. Entitlement to service connection for a left lower extremity(sciatic) nerve disorder is granted. Entitlement to service connection for a right lower extremity (sciatic) nerve disorder is granted. REMAND As to the remaining cervical spine disorder and for left and right upper extremity nerve disorders service connection issues on appeal, the May 2015 remand directives asked for an opinion as to whether a present disorder was a result of service. The examiner was asked to consider a May 2014 private medical opinion relating the Veteran's cervical spine disorder to his thoracic and lumbar spine disabilities. The Veteran underwent a VA cervical spine examination in November 2015 and an opinion as to secondary service connection was provided. However, the examiner neither acknowledged nor addressed the May 2014 opinion. No opinion was provided as to the direct service connection aspect of the claim. A remand by the Board confers on a veteran or other claimant, as a matter of law, the right to compliance with the remand orders. See Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that a March 2018 brief in support of these claims asserted that the evidence of record had not adequately considered a January 1985 service treatment report noting complaints of upper back pain and tingling in the fingers. It is also significant to note that private treatment records dated in April 2003 noted the Veteran had developed neck and back pain after an MVA involving an 18-wheel truck. That examiner noted that the present symptoms were probably all due to mechanical strain, but that paresthesia in the hands raised the question of a spinal cord or nerve root injury. A May 2003 report noted magnetic resonance imaging (MRI) revealed mild cervical spondylosis with no evidence of anything related to trauma. The record includes additional evidence of injuries sustained in an MVA in 1996 and in a July 2012 fall in a hotel bathtub. In light of the complexity of the medical issues involved, further development as to these matters is required prior to appellate review. VA's duty to assist the Veteran includes obtaining a thorough and contemporaneous examination where necessary to reach a decision on a claim. See 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2017); see also El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (indicating that findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under § 3.310(b)). Here, the Board finds another VA medical opinion is required. Prior to any examination, up-to-date VA treatment records should be obtained. Accordingly, the case is REMANDED for the following action: 1. Obtain all pertinent VA medical records not yet associated with the appellate record. 2. Obtain a clarifying VA medical opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran has present cervical spine and/or left and right upper extremity nerve disorders that: a. had its onset in service, or b. is etiologically related to his active service, or c. was caused by his service-connected thoracolumbar spine (degenerative disc disease) disability, or d. was aggravated by his service-connected thoracolumbar spine disability. The examiner must acknowledge review of the pertinent evidence of record, including a January 1985 service treatment report, an April 2003 private treatment report, and a May 2014 private medical opinion. All necessary examinations, tests, and studies should be conducted. Rationale for the requested opinion shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, provide an explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or the limits of current medical knowledge with respect to the question. 3. Thereafter, the AOJ should address the issues remaining on appeal. If the benefit sought is not granted to the Veteran's satisfaction, the Veteran and his attorney should be furnished a Supplemental Statement of the Case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). _________________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs