Citation Nr: 1827705 Decision Date: 05/01/18 Archive Date: 05/14/18 DOCKET NO. 11-01 743 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUES 1. For the period prior to January 23, 2008, entitlement to an initial evaluation in excess of 20 percent for degenerative disc disease (DDD) of the cervical spine, status post C6-7 discectomy ("cervical spine disability"). 2. From January 23, 2008, entitlement to an initial evaluation in excess of 30 percent for a cervical spine disability. 3. Entitlement to service connection for a jaw disability. ATTORNEY FOR THE BOARD J. Juliano, Counsel INTRODUCTION The Veteran served on active duty in the U.S. Marine Corps from December 1966 to December 1969, and in the U.S. Navy from March 1971 to February 1972. These matters come before the Board of Veterans' Appeals (Board) on appeal from May 2009 and April 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island. A November 2010 rating decision awarded an earlier effective date of January 23, 2008, for the 30 percent initial rating for the cervical spine disability (previously the 30 percent rating was effective from March 18, 2009). As this did not constitute a grant of the full benefit sought on appeal, the initial rating matters remain on appeal before the Board. A June 2014 Board decision awarded an earlier effective date of September 19, 1996 for service connection for the Veteran's cervical spine disability. See also Rating decision, June 2014. The June 2014 Board decision also remanded the matters on appeal herein for further development. These matters are now returned to the Board for further appellate review. This appeal was processed using the VBMS paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The issue of entitlement to service connection for a jaw disability is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to January 23, 2008, the Veteran's cervical spine disability manifested by pain and flexion limited to 23 degrees; there is no evidence of forward flexion limited to 15 degrees, favorable ankylosis of the entire cervical spine, or incapacitating episodes requiring bed rest prescribed by a physician. 2. From January 23, 2008, the Veteran's cervical spine disability is manifested by pain, flexion limited to 15 degrees, and fusion at C6-7; there is no evidence of unfavorable ankylosis of the entire cervical spine, or incapacitating episodes requiring bed rest prescribed by a physician. 3. For the entire period on appeal, the Veteran's left occipital neuralgia associated with his cervical spine disability is productive of, at most, mild symptoms of pain; no paralysis is shown. 4. From December 12, 2001, the Veteran's right occipital neuralgia associated with his cervical spine disability is productive of, at most, mild symptoms of pain; no paralysis is shown. 5. For the entire period on appeal, the Veteran's left upper extremity radiculopathy associated with his cervical spine disability is productive of, at most, mild symptoms of pain and decreased sensation; no paralysis is shown. CONCLUSIONS OF LAW 1. Prior to January 23, 2008, the criteria for an initial evaluation in excess of 20 percent for a cervical spine disability are not met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2017). 2. From January 23, 2008, the criteria for an initial evaluation in excess of 30 percent for a cervical spine disability are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2017). 3. For the entire period on appeal, the criteria for an evaluation of 20 percent for left occipital neuralgia associated with the Veteran's cervical spine disability are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.120, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2017). 4. From December 12, 2001, the criteria for an evaluation of 20 percent for right occipital neuralgia associated with the Veteran's cervical spine disability are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.120, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2017). 5. For the entire period on appeal, the criteria for an evaluation of 20 percent for left upper extremity radiculopathy associated with the Veteran's cervical spine disability are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.120, 4.123, 4.124, 4.124a, Diagnostic Code 8520 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist With regard to the Veteran's cervical spine disability rating claim, the Board finds that VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5102, 5103(a), 5103A, 5106 (2012); 38 C.F.R. §§ 3.159, 3.326(a) (2017). The Board notes that where service connection has been granted and an initial rating has been assigned, the claim of service connection has been more than substantiated, as it has been proven. As such, 38 U.S.C. § 5103(a) notice is no longer required since the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C. § 5103(a) notice. Therefore, any defect as to 38 U.S.C. § 5103(a) notice is nonprejudicial. See Dingess v. Nicholson, 19 Vet. App. 473, 490-491 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). The Board also finds that VA's duty to assist has been satisfied. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). The Veteran's VA treatment records and private treatment records are all in the claims file. The Veteran has not identified any outstanding VA or private treatment records for VA to obtain. In June 2014, the Board remanded the claim so that the Veteran could be afforded a new VA examination, including to address any neurological manifestations, and to provide a retroactive opinion (to the extent possible) regarding the severity of the Veteran's disability since September 1996. Subsequently, the Veteran was afforded a February 2018 VA examination. The Board acknowledges that the VA examiner did not provide a retroactive opinion regarding the severity of the Veteran's cervical spine disability from 1996. However, the VA examiner explained that the Veteran refused to perform range of motion testing. The duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In this case, the Veteran is assigned a 20 percent rating for the period from September 19, 1996 to January 22, 2008 (and 30 percent thereafter). The rating criteria provide for a higher 30 percent rating for forward flexion of the cervical spine of 15 degrees or less, or favorable ankylosis of the entire cervical spine. Thus, range of motion results were central to the inquiry as to whether a higher rating was warranted retroactively. As the Veteran failed to cooperate with the examination, the Board must rate the disability on the evidence of record. The examiner did, however, complete the VA examination to the extent possible, and he did address the Veteran's history of neurological manifestations and provide retrospective assessments of the manifestations as requested by the Board. Also, the Board directed in the June 2014 remand that the AOJ provide the Veteran with another opportunity to identify any outstanding treatment records for VA to obtain, but no response was ever received. Therefore, the Board finds there was substantial compliance with the Board's remand directives, and that VA's duty to assist in that regard has been satisfied. Neither the Veteran nor his representative identified any other shortcomings in fulfilling VA's duty to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Therefore, for the above reasons, the Board finds the duties to notify and assist have been met, all due process concerns have been satisfied, and the appeal may be considered on the merits. II. Analysis The Veteran served on active duty in the U.S. Marine Corps from December 1966 to December 1969, and in the U.S. Navy from March 1971 to February 1972. He contends that his cervical spine disability is more severe than as contemplated by the assigned initial ratings. Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment of earning capacity. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7 (2017). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2017). When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. See 38 U.S.C § 5107(b) (2012). Where, as in the instant case, an appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). With regard to the cervical spine, the General Rating Formula for Diseases and Injuries of the Spine (DCs 5235-5242) provides a 10 percent disability rating for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent disability rating is assigned for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent disability rating is assigned for forward flexion of the cervical spine of 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent disability rating is assigned for unfavorable ankylosis of the entire cervical spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. Note 1 to the General Rating Formula provides for a separate evaluation for any associated, objective neurologic abnormalities. 38 C.F.R. § 4.71a (2017). Diagnostic Code 5243 provides for rating intervertebral disc syndrome (IVDS) under the General Rating Formula for Diseases and Injuries of the Spine, or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2017). The Formula for Rating IVDS Based on Incapacitating Episodes provides ratings for incapacitating episodes as follows: having a total duration of at least 6 weeks during the past 12 months (60 percent); having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months (40 percent); having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months (20 percent); and having a total duration of at least one week but less than 2 weeks during the past 12 months (10 percent). 38 C.F.R. § 4.71a. An incapacitating episode is defined as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note 1 (2017). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. Where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. Subjective pain in and of itself will not establish a current disability. Consideration must be given to the impact, or lack thereof, from pain, focusing on evidence of functional limitation caused by pain. Saunders v. Wilkie, No. 2017-1466, 2018 U.S. App. LEXIS 8467 (Fed. Cir. Apr. 3, 2018). The Veteran's cervical spine disability is currently assigned a 20 percent disability rating under Diagnostic Code 5242 effective September 19, 1996, and a 30 percent rating effective January 23, 2008. The Veteran seeks higher initial ratings. See Notice of Disagreement, July 2009. A June 1996 private facility record from Charleston Hospital shows the Veteran's cervical flexion was limited to 23 degrees (noted as "50 percent"). See Treatment records, received May 1991 at p.22 of 37; see also 38 C.F.R. § 4.71a, General Rating Formula For Diseases and Injuries of the Spine, Note (2) (normal range of cervical flexion is zero to 45 degrees). The Veteran was afforded VA examinations in March 2009 and February 2018. The March 2009 VA examination report shows the examiner noted the Veteran's history of the April 1996 microdiscectomy at C6-7. The examiner noted that a May 2000 MRI revealed disc bulging and foraminal narrowing at C3-5, and C6-7, but "no change from September 1996." The Veteran reported constant daily and severe cervical pain and left arm achiness. He reported no flare-ups, no incapacitating episodes of spine disease, and no ankylosis. Strength testing of the upper extremities was 4/5 to 5/5 bilaterally. Sensory examination of the upper extremities was 1/2 to 2/2 bilaterally. The examiner noted there was peripheral sensory loss in both upper extremities. Range of motion testing of the cervical spine revealed flexion to 15 degrees, with objective evidence of painful motion noted. No additional limitation of motion was found on repetitive use testing. The examiner noted that a June 2006 MRI showed moderate to severe spondylosis at C3-7 levels, and fusion at the C6-7 level. The examiner noted the Veteran retired in 1991 from working as an outside machinist at a shipyard. The examiner diagnosed cervical spondylosis/chronic cervical radiculopathy, and a cervical myofascial disorder. The February 2018 VA examination report shows the examiner noted that a 2017 MRI showed multilevel disc disease from C2-C6 with bilateral foraminal narrowing at multiple levels. He reported sometimes he can barely move his neck, and that his condition had worsened in the last year. He reported no flare-ups. The examiner noted that the Veteran was unwilling to perform range of motion testing. The examiner noted he was unable to opine as to the presence of ankylosis because the Veteran refused to perform range of motion testing. Strength testing was 5/5 in the upper extremities. No muscle atrophy was found. The examiner noted that the Veteran has IVDS, but noted that he did not have any episodes of acute signs and symptoms that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. Sensory examination was normal in the right upper extremity, but decreased in the left upper extremity. The examiner noted that the Veteran reported loss of sensation in the entire left upper extremity. Later in the report, however, the examiner opined that the Veteran's left upper extremity symptoms were exaggerated and/or non-physiologic. The examiner reasoned that while the Veteran reported loss of sensation in his entire left upper extremity, imaging revealed neuroforaminal narrowing only at C2-6, and cited the fact that the Veteran provided poor effort on strength testing, examination was not significant for any objective weakness, and reflex examination was within normal limits. Regarding the Veteran's history of treatment for occipital neuralgia, the examiner noted that it originates in the first three cervical nerves, C1-3. The Board has reviewed all of the Veteran's VA and private treatment records, none of which show symptoms more severe than those shown on examination above with regard to the Veteran's cervical spine disability (neurologic manifestations, however, are addressed below). For the period prior to January 23, 2008, the Board finds that the preponderance of the evidence is against finding that the criteria for a rating in excess of 20 percent for the Veteran's cervical spine disability are met or approximated. As shown above, forward flexion has never been shown during this period of time to be limited to 15 degrees or less, and no favorable or unfavorable ankylosis of the entire cervical spine is shown. As noted above, the June 1996 Charleston Hospital record shows forward flexion was limited to 23 degrees. The Board further finds that the Veteran is not shown to meet the criteria for a higher rating under the Formula for Rating IVDS because no incapacitating episodes of IVDS are shown. The Board acknowledges that no VA examination was conducted during this period prior to January 23, 2008. As explained in the notice and assistance section, however, the Board recently remanded this claim for a retroactive VA medical opinion to address the severity of the Veteran's cervical spine disability (to the extent possible) prior to January 23, 2008. The rating criteria provide for a higher rating based on limitation of motion or ankylosis. The Veteran, however, refused to perform range of motion testing. The examiner also noted that because the Veteran refused to perform range of motion testing, he could not opine as to ankylosis. Moreover, in 2009, an examiner noted no change in the underlying pathology since 1996. Thus, it is due to the Veteran's failure to cooperate with the examination that no retroactive opinion could be provided, and the Board must rate the disability based on the available evidence of record. For the period beginning on January 23, 2008, the Board finds that the preponderance of the evidence is against finding that the criteria for a rating in excess of 20 percent for the Veteran's cervical spine disability are met or approximated. As shown above, unfavorable ankylosis of the entire spine has never been shown. The Veteran was able to perform range of motion testing at the March 2009 VA examination, and the examiner noted there was fusion only at C6-7. As addressed in detail above, the Veteran refused to perform range of motion testing at the February 2018 VA examination, and the examiner noted that he was therefore unable to opine as to whether ankylosis was present. The Board further finds that the Veteran is not shown to meet the criteria for a higher rating under the Formula for Rating IVDS because no incapacitating episodes are shown. With regard to assigning higher ratings according to 38 C.F.R. § 4.40 and 4.45, the Board acknowledges the Veteran's reported complaints of pain. The Board has considered pain as limiting his ranges of motion as described above (i.e., as limiting his ranges of motion as shown on VA examination). The Board finds, however, that painful motion is already contemplated by the currently assigned 20 and 30 percent ratings. In addition, there is no objective evidence of record reflecting that the Veteran experiences additional functional loss or limitation of motion due to symptoms such as pain, weakness, weakened movement, excess fatigability, or incoordination, beyond that already noted by all of the VA examiners. The Board acknowledges that the Veteran has cited the fact that an August 1996 record by Dr. L.S. (the neurosurgeon who performed the April 1996 discectomy) shows "severe" limitation of motion was noted. See Correspondence, December 2013; PTRs, received June 1995. The Board notes, however, that these symptoms were noted for only three weeks, the specific ranges of motion were not provided in that record, no ankylosis of the entire spine was noted, and Dr. L.S. noted therein that it appeared there was some overlap between a right shoulder condition and his cervical spine disability causing the presenting complaints at that time. Moreover, this was only four months after the April 1996 surgical procedure. Also, shortly prior to, a March 1996 record by Dr. L.S. shows he noted that an MRI revealed an osteophyte at C6-7 on the left with compromise of the neuroforamen and "mild" degenerative changes at other levels. See PTRs, received June 1995. Regarding any associated neurological manifestations, the Board acknowledges that the medical evidence shows the Veteran was diagnosed with left C2-3 neuropathy in 1995, later changed to left occipital neuralgia in 1999, and treated for right occipital neuralgia beginning in December 2001, as discussed in greater detail below. Occipital neuralgia is "acute pain radiating along the course of nerve or nerves in back of the skull." Blanchard v. Derwinski, 3 Vet. App. 300, 301 (1992). Diagnostic Code 8713, pertaining to neuralgia of all cervical radicular groups, provides a 20 percent rating for mild incomplete paralysis, 30 percent for moderate (minor), and 60 percent for severe (minor); and an 80 percent rating for complete paralysis (minor). 38 C.F.R. § 4.124a (2017). Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124 (2017). A June 1995 record by Dr. D.K. shows the Veteran reported pain in his left neck spreading up into the mandible, and a sharp pain in the left occipital area. Dr. D.K. diagnosed left C2-3 neuropathy, and he recommended nerve blocks. See Congressionals, received June 1995; see also PTRs, received January 2000 (July 1999 Dr. D.K. record regarding C2-3 neuropathy and nerve blocks). January 1999 to September 2003 records from St. Anne's Hospital show that the diagnosis was changed to left occipital neuralgia, and the Veteran received left occipital nerve blocks. See PTRs, received March 2004 at p.51. December 2001 and March 2002 records also show the Veteran was given right occipital nerve blocks after reporting similar symptoms of "facial pain" on the right side. See id. at p.13-15 of 52. St. Anne's records dated since December 2002 show that bilateral occipital neuralgia was diagnosed. See PTRs, received August 2016 at p.8-10. A January 2008 record by Dr. L.S. shows he opined that the Veteran's left occipital neuralgia is related to his DDD of the cervical spine. He reasoned that the DDD caused stiffness of cervical musculature, which in turn caused the occipital neuralgia. See PTRs, received June 2008. A February 2018 VA examination report and opinion (relating specifically to the left occipital neuralgia) shows the examiner opined that the Veteran has bilateral occipital neuralgia that is related to his cervical spine, reasoning that it relates to the first three cervical nerves (C1-3). The examiner noted the Veteran experiences bilateral pain that radiates up and over the apex and to the frontal area due to his occipital neuralgia, that the Veteran had been receiving occipital nerve blocks three to four times per year since the mid-1990s, and that the treatment records showed they were "very effective" in treating the condition. In light of the above, the Board finds that a separate 20 percent rating under Diagnostic Code 8713 for the Veteran's left occipital neuralgia associated with his cervical spine disability (C1-3) is warranted for the entire period on appeal, and that a 20 percent rating for right occipital neuralgia is warranted effective from December 12, 2001, the first date that symptoms were shown. The Veteran was diagnosed with left C2-3 neuropathy, later changed to left occipital neuralgia, back in 1995 prior to the period on appeal. He was not shown to experience symptoms of right occipital neuralgia until December 12, 2001 (see St. Anne's Hospital, December 2001). Diagnostic Code 8713 provides for a 20 percent rating for mild symptoms. As shown above, the March 1996 record by Dr. L.S. shows the Veteran only had "mild" degenerative changes of the cervical spine at C1-3. The February 2018 VA examiner noted that the Veteran's occipital neuralgia originates from C1-3, and that the occipital nerve blocks have been "very effective" in treating the Veteran's symptoms. While the Board acknowledges that the February 2018 VA examiner characterized the Veteran's occipital neuralgia symptoms as akin to headaches, the Board notes that under Diagnostic Code 8100, pertaining to migraine headaches, the Veteran's symptoms would not meet the criteria for a compensable evaluation because characteristic prostrating attacks are not shown. See 38 C.F.R. § 4.124a. The Board is also cognizant that the Veteran has maintained for years that he experiences facial pain (and he believes there is a component relating to his 1971 jaw surgery in service, which is addressed in the remand section below involving his service connection claim). Therefore, the 20 percent rating assigned herein under Diagnostic Code 8713 is more appropriate. In addition, the Board also acknowledges that several medical records show that the Veteran has left upper extremity radiculopathy originating from C7. Diagnostic Code 8511, middle radicular group (cervical), provides a 20 percent rating for mild incomplete paralysis, 30 percent for moderate (minor), and 40 percent for severe (minor); and an 60 percent rating for complete paralysis (minor). 38 C.F.R. § 4.124a (2017). Specifically, a June 1995 record by Dr. R.B. shows the Veteran reported experiencing left hand numbness, examination revealed decreased left extremity sensation, an MRI showed diffuse cervical degenerative changes, and Dr. R.B. diagnosed cervical discogenic disease and osteoarthritis. See Congressionals, September 1995. A March 1996 record by Dr. L.S. shows he noted the Veteran reported left arm pain, and that he tended to drop items with his left hand. Strength testing of the upper extremities was normal, and sensory examination was not remarkable, but deep tendon reflexes were 1/4. See PTRs, received June 1995. Dr. L.S. noted that an MRI revealed an osteophyte at C6-7 on the left with compromise of the neuroforamen at that level, and Dr. L.S. opined that the Veteran had C7 radiculopathy related to the change at the C6-7 level. An April 1996 record from Charleston Hospital notes diagnosed left radiculopathy. See Treatment records, received May 1991 at p.9-12 of 37. The March 2009 VA examination report shows the Veteran reported cervical pain and left arm achiness, examination showed strength testing was 4/5 to 5/5, and sensory examination was 1/2 to 2/2, and the examiner diagnosed cervical radiculopathy. The February 2018 VA examination report shows the Veteran strength testing of the upper extremities was 5/5, and sensory examination was normal in the right but decreased for the left upper extremity. Although the Veteran reported loss of sensation in the entire upper extremity, the examiner opined that the Veteran's report was exaggerated and/or non-physiologic. The examiner reasoned that while the Veteran reported loss of sensation in his entire left upper extremity, imaging revealed neuroforaminal narrowing only at C2-6, and the examiner cited the fact that the Veteran provided poor effort on strength testing, examination was not significant for any objective weakness, and reflex examination was within normal limits. While the Board acknowledges that, ultimately, this VA examiner checked the box in the report finding that the Veteran does not have radiculopathy, the Board nevertheless acknowledges that prior medical records did find left upper extremity radiculopathy, and that this February 2018 VA examiner did acknowledge that imaging showed neuroforaminal narrowing only at C2-6, and sensation was decreased on examination. Therefore, the Board will resolve all doubt in the Veteran's favor and find that, while his symptoms appear to be exaggerated at the time of the February 2018 VA exam, he nevertheless has experienced left upper extremity radiculopathy. In light of the above, the Board finds that a separate 20 percent rating under Diagnostic Code 8511 is warranted for the Veteran's left upper extremity radiculopathy involving the C7 nerve for the entire period on appeal. As shown above, the medical evidence shows decreased sensation and pain, and diagnosed left upper extremity radiculopathy (C7) dating back to 1996. The March 2009 VA examiner noted strength was 4/5, and the February 2018 VA examiner found it to be normal. Both VA examiners found decreased sensation, noted as 1/2 to 2/2 by the March 2009 VA examiner. The Board has also taken into account the fact that the February 2018 VA examiner found the Veteran's reported symptoms were exaggerated or non-physiologic because they were not consistent with diagnostic test results. Thus, the Board finds the Veteran's symptoms are contemplated by, at most, the 20 percent criteria for "mild" incomplete paralysis. In this case, the Veteran has not contended, and the evidence does not suggest, that he has experienced symptoms outside of those listed in the schedular criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (Board is not obligated to analyze whether remand for referral for extraschedular consideration is warranted if "§ 3.321(b)(1) [is] neither specifically sought by [the claimant] nor reasonably raised by the facts found by the Board") (quoting Dingess v. Nicholson, 19 Vet.App. 473, 499 (2006), aff'd, 226 Fed. Appx. 1004 (Fed. Cir. 2007)). In summary, the Board concludes that initial ratings for the Veteran's cervical spine disability in excess of 20 percent prior to January 23, 2008, and in excess of 30 percent thereafter, are not warranted; separate ratings of 20 percent (each) for left and right occipital neuralgia (C1-3), and 20 percent for left upper extremity radiculopathy (C7), associated with the cervical spine disability are granted herein; the benefit of the doubt rule is not for application. ORDER For the period prior to January 23, 2008, entitlement to an initial evaluation in excess of 20 percent for a cervical spine disability is denied. From January 23, 2008, entitlement to an initial evaluation in excess of 30 percent for a cervical spine disability is denied. For the entire period on appeal, a separate 20 percent rating for left occipital neuralgia (C1-3) is granted. From December 12, 2001, a separate 20 percent rating for right occipital neuralgia (C1-3) is granted. For the entire period on appeal, a separate 20 percent rating for left upper extremity radiculopathy (C7) is granted. REMAND The Veteran served on active duty in the U.S. Marine Corps from December 1966 to December 1969, and in the U.S. Navy from March 1971 to February 1972. He claims that he has a jaw disability that was caused or aggravated by his active service. See Correspondence, November 2013. As an initial matter, the Board also acknowledges that no jaw condition was noted on entry in the August 1966, May 1967, and January 1971 enlistment examination reports and, therefore, the presumption of soundness applies. See 38 U.S.C. § 1111 (2012). During his service, a March 1971 service treatment record shows the Veteran reported a history of a molar extraction in June 1969 and of a mortar round landing on his right cheek; and he reported right facial numbness. See STRs, received February 2009 at p.38 of 84. The Board also acknowledges that the Veteran's DD Forms 214 and 215 relating to his service in the Marines indicate that he served as a rifleman in Vietnam, and that he is the recipient of a Combat Action Ribbon. His November 1969 separation examination notes scars, but the locations are unfortunately illegible. See STRs, received March 2016 at p.52. A June 1971 narrative summary shows the Veteran reported right temporomandibular joint symptoms and masticatory dysfunction due to a prognathic mandible that was noted as existing prior to service. Prognathic reduction surgery was performed, and then in August 1971, intermaxillary tie wires were discontinued and it was noted that the Veteran demonstrated good clinical healing of the surgically corrected mandible. See STRs, copies uploaded March 2016 at p.92 of 104. It was also noted that he would subsequently be fitted for a dental prosthesis. See id. The June 1971 operative report shows that the following was performed: osteotomy, vertical of mandible, bilateral, #189, maxillary corticotomy, tooth #6 #189, application of maxillary splint and intermaxillary fixation, #189. See Service treatment record, received January 2005. The Board notes that Veteran contends that he has experienced facial pain and numbness since the June 1971 surgical procedure. See Correspondence, November 2013. Post-service, a July 1974 VA treatment record shows the Veteran reported pain in the left condyle area, and poor right occlusion was noted. See VA treatment records, received May 1991 at p.3 of 4. In January 1991, the Veteran reported pain at the angle of the mandible, and surgery for removal of symptomatic hardware was performed. See VA treatment records, received March 1991 and August 2016. A June 1995 record by Dr. D.K. shows the Veteran reported pain in his left neck spreading up into the mandible, and a sharp pain in the left occipital area. Dr. D.K. diagnosed left C2-3 neuropathy, and he recommended nerve blocks. See Congressionals, received June 1995. June 1995 and July 1995 records by Dr. R.B. show the Veteran reported left jaw pain, and that after Dr. R.B. performed a cervical steroid injection, on follow-up, the Veteran reported that he felt "excellent" for five days, but then the pain returned to baseline. See VA Form 10-10 records, received June 1995 at p.12 and 15 of 22. As discussed above, the Veteran has been granted service connection for bilateral occipital neuralgia herein, for which he has received nerve blocks since the mid-1990s. A September 1997 VA medical opinion, and an August 1998 independent medical expert opinion, show the examiners both opined, in short, that the Veteran had a preexisting prognathic mandible that was improved by the in-service surgery in 1971. A February 1998 opinion of Dr R.F., VA Acting Assistant Medical Director for Dentistry, shows he opined that the Veteran's preexisting prognathic jaw was developmental in nature, but no further opinion was offered. See VA memo, March 1998. Similarly, a July 1999 record by Dr. D.K., an oral and maxillofacial surgeon, shows he noted there was "no pathology in the mandible or maxilla, [and] the anatomy of the temporomandibular joints appeared grossly normal," and he opined the Veteran had a TMD disorder due to an ill-fitting denture with inadequate occlusion. See PTRs, received January 2000. By contrast, a May 2000 record by Dr. L.S., a neurosurgeon, shows that he acknowledged the Veteran's left occipital neuralgia, but also opined that the Veteran's complaints of numbness in his lip and jaw area are due to trauma to the inferior alveolar nerve that likely occurred at the time of the 1971 jaw surgery. See PTR, received June 2000. Similarly, a June 2013 record by Dr. J.S., of the Harvard Dental Center, shows the Veteran reported jaw pain, and Dr. J.S. diagnosed trigeminal neuropathy caused by nerve damage from the 1971 surgery. He also diagnosed left TMJ arthralgia related to disc displacement, but opined that it was not related to the 1971 jaw surgery. See PTRs, received November 2013. Finally, a July 2013 record by Dr. N.M., of the Tufts School of Dental Medicine, shows he diagnosed a TMJ disorder, and opined that the Veteran has muscle pain and tenderness due to long term loss of vertical dimension and disturbed muscle coordination and function. See PTRs, received December 2013. As shown above, the Veteran reports pain and numbness in his jaw since the 1971 prognathic reduction surgery. It is unclear, however, given the above conflicting opinions, whether his reports of pain and numbness are attributable to his already service-connected occipital neuralgia, or to an ill-fitting denture with poor occlusion, or whether it relates to injury involving the inferior alveolar nerve or trigeminal nerve that was caused or aggravated by the 1971 surgery. Therefore, regrettably, the Board finds that this matter should be remanded so that a new VA examination may be performed for clarification. His history of reporting in March 1971 a history of a molar extraction and a right cheek laceration due to a mortar round, and complaint of right cheek numbness, should also be addressed, as well as the July 2013 record by Dr. N.M. showing a diagnosed a TMJ disorder due to long term loss of vertical dimension and disturbed muscle coordination and function. Accordingly, the case is REMANDED for the following action: 1. Afford the Veteran a VA examination by a neurologist to address the nature and etiology of his claimed jaw disability manifested by pain and numbness. The complete claims folder must be provided to the examiner for review in conjunction with the examination, and the examiner must note that the claims folder has been reviewed. The examiner should opine as to whether it is "at least as likely as not" that the Veteran's claimed jaw disability manifested by complaints of pain and numbness, is related to a) the June 1971 prognathic jaw reduction surgery in service, or b) his report in March 1971 of a right cheek laceration from a mortar round and right cheek numbness. See Operative report, received January 2005; see also STRs received March 2016 at p.92 of 104; and STRs, received February 2009 at p.38 of 84. Request that the VA examiner clarify whether the Veteran's complaints of jaw pain and numbness are manifestations of his already service connected bilateral occipital neuralgia. Also, the VA examiner must address the May 2000 record by Dr. L.S. in which she opined the Veteran incurred an inferior alveolar nerve injury due to the 1971 surgery. See PTR, received June 2000. The VA examiner must also address the July 2013 record by Dr. J.S. of the Harvard Dental Center in which he diagnosed trigeminal neuropathy caused by nerve damage from the 1971 surgery. See PTR, received November 2013. Any opinion must be accompanied by a complete rationale. 2. After the above development has been completed, afford the Veteran a VA examination by a VA oral and maxillofacial surgeon. The complete claims folder must be provided to the examiner for review in conjunction with the examination, including a copy of the VA neurology examination report requested by the Board herein, and the examiner must note that the claims folder has been reviewed. The examiner should opine as to whether there is "clear and unmistakable evidence" that the Veteran's prognathic mandible preexisted service, and if so, whether there is "clear and unmistakable evidence" that it was not aggravated by service beyond the natural progress of the disease. This examiner must also clarify whether the Veteran's complaints of jaw pain and numbness are due to a) poor occlusion due to his dentures, or b) TMJ disorder due to long term loss of vertical dimension and disturbed muscle coordination and function, and if so, whether this was caused or aggravated by the 1971 in-service prognathic reduction surgery. See VAMC records, received May 1991 at p.3 of 4 (July 1974); PTRs, received January 2000 (July 1999 - Dr. D.K.), and PTRs, received December 2013 (Tufts). The examiner should also address the Veteran's March 1971 service treatment record showing the Veteran reported a history of a molar extraction in 1969, and his report of right facial numbness. See STRs, received February 2009 at p.38 of 84. Any opinion must be accompanied by a complete rationale. 3. Then, readjudicate the Veteran's claim. If the claim remains denied, the Veteran should be provided with a Supplemental Statement of the Case (SSOC). After the Veteran has been given the applicable time to submit additional argument, the claim should be returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matters that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). ____________________________________________ J.W. FRANCIS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs