Citation Nr: 18112273 Decision Date: 06/20/18 Archive Date: 06/19/18 DOCKET NO. 11-24 057 DATE: June 20, 2018 ORDER A 70 percent rating for dysthymic disorder associated with Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord is granted since May 17, 2010. A 30 percent rating for a disfiguring scar of the neck associated with Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord is granted since May 17, 2010. A rating in excess of 10 percent for two stable, but painful, scars associated with Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord is denied since May 17, 2010. A 60 percent rating for right upper extremity radiculitis associated with Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord is granted since May 17, 2010. A rating in excess of 30 percent under 38 C.F.R. § 4.124a, Diagnostic Code 8024, for Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord since May 17, 2010, is denied. REMANDED 1. A determination of whether lumbar spine complaints are a residual of the Veteran’s service-connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord is remanded. 2. A determination of whether dizziness is a residual of the Veteran’s service connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord is remanded. 3. A determination of whether blurred vision is a residual of the Veteran’s service connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord is remanded. 4. A determination of whether headaches are a residual of the Veteran’s service connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord is remanded. 5. A determination of whether erectile dysfunction is a residual of the Veteran’s service-connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord is remanded. 6. A determination of whether left upper extremity complaints are a residual of the Veteran’s service-connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord is remanded. FINDINGS OF FACT 1. During the period on appeal, the Veteran’s dysthymic disorder caused gross impairment in thought processes or communication, depressed mood, low energy, anxiety, chronic sleep impairment, disturbances of motivation and mood, poor concentration, fatigue, isolation, decrease in social interactions and physical activities, work-related stress, irritability and anger, flattened affect, disturbances of motivation and mood, difficulty adapting to stressful circumstances, suicidal and homicidal ideation, and an intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene. 2. During the period on appeal, the Veteran had two painful, but stable scars, one of which was of the neck and had two characteristics of disfigurement. 3. During the period on appeal, the Veteran’s right (minor) upper extremity radiculitis caused weakness, moderate numbness, tingling, moderate constant pain, moderate paresthesias and/or dysesthesias, decreased strength, an absence of reflexes, decreased elbow and wrist flexion and extension, decreased grip, decreased pinch, decreased sensations, right upper extremity muscle weakness, and right hand muscle atrophy. 4. The Schedule For Rating Disabilities and the M21-1 do not allow for a rating in excess of 30 percent under diagnostic code 8024. This diagnostic code merely sets a minimum rating of 30 percent for syringomyelia; any increase beyond that is based on ratings assigned for residuals under the appropriate diagnostic codes. CONCLUSIONS OF LAW 1. The criteria for a rating of 70 percent, since May 17, 2010, for dysthymic disorder have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.14, 4.130, Diagnostic Code 9433 (2017); M21 1.III.iv.4.N.5.b. 2. The criteria for a rating of 30 percent, since May 17, 2010, for a disfiguring scar of the neck have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.14, 4.118, Diagnostic Code 7800 (2017); M21 1.III.iv.4.N.5.b. 3. The criteria for a rating in excess of 10 percent since May 17, 2010, for two stable, but painful scars, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.14, 4.118, Diagnostic Code 7804 (2017); M21 1.III.iv.4.N.5.b. 4. The criteria for a rating of 60 percent, since May 17, 2010, for right upper extremity radiculitis have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.124a, Diagnostic Code 8513 (2017); M21 1.III.iv.4.N.5.b. 5. The Schedule For Rating Disabilities and the M21-1 do not permit a rating in excess of 30 percent under diagnostic code 8024. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.14, 4.124a, Diagnostic Code 8024 (2017); M21 1.III.iv.4.N.5.b. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Marine Corps from March 1984 to August 1993. In May 2012, the Veteran was afforded a videoconference hearing before the undersigned Veterans Law Judge. In April 2014 and November 2014, the Board remanded the appeal. In July 2016 the Board increased the rating assigned to the Veteran’s dysthymic disorder; denied an increase in the cervical spine limitation of motion and neck scars ratings; and remanded the right and left upper extremity neurologic symptoms ratings. The Veteran subsequently appealed to the United States Court of Appeals for Veterans’ Claims (Court). In July 2017, the Court granted the Parties’ Joint Motion for Partial Remand (JMPR); vacated the portion of the July 2016 Board decision which denied an increase in the neck scars and dysthymic disorder ratings; and remanded the Veteran’s appeal to the Board. Entitlement to an increased rating for Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord since May 17, 2010. Disability evaluations are determined by comparing the Veteran’s current symptomatology with the criteria set forth in the Schedule For Rating Disabilities. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2017). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Syringomyelia is rated according to diagnostic code 8024 and a minimum 30 percent rating is warranted. 38 C.F.R. § 4.124a, Diagnostic Code 8024 (2017). The diseases and residuals listed in 38 C.F.R. § 4.124a may be rated from 10 percent to 100 percent in proportion to the impairment of motor, sensory, or mental function. Psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, visceral manifestations, etc. are to be especially considered and should be rated by referring to the appropriate bodily system of the rating schedule. 38 C.F.R. § 4.124a. The Note to diagnostic code 8024 states: It is required for the minimum ratings for residuals under diagnostic codes 8000-8025, that there be ascertainable residuals. Determinations as to the presence of residuals not capable of objective verification, i.e., headaches, dizziness, fatigability, must be approached on the basis of the diagnosis recorded; subjective residuals will be accepted when consistent with the disease and not more likely attributable to other disease or no disease. It is of exceptional importance that when ratings in excess of the prescribed minimum ratings are assigned, the diagnostic codes utilized as bases of evaluation be cited, in addition to the codes identifying the diagnoses. 38 C.F.R. § 4.124a. The M21-1 provides further guidance on rating a claim for syringomyelia, as the rating criteria are identical to those listed for multiple sclerosis (MS) under diagnostic code 8018. 38 C.F.R. § 4.124a. The procedure for rating MS was changed in June 2015. The M21-1 now provides that, for MS disability residuals totaling 30 percent or more, each affected system or body part should be rated separately, the diagnostic code for MS should be used only once by listing it with the most severely affected function, the other manifestations should be coded under the diagnostic code assignable for the condition on which the rating is based, and the remaining conditions should be listed as secondary to MS. If the combined rating for all disabilities due to MS is 20 percent or less, a 30 percent rating is assigned under 38 C.F.R. § 4.124a, Diagnostic Code 8018. See M21 1.III.iv.4.N.5.b. The Veteran is currently in receipt of a 30 percent rating for Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord under 38 C.F.R. § 4.124a, Diagnostic Code 8024, in addition to the ratings assigned for residuals of dysthymic disorder, limited cervical motion, right upper extremity radiculitis, and neck scars. Based on the M21-1 guidance, the Veteran should be rated solely for his residuals which total a 30 percent or greater. A separate rating under diagnostic code 8024 should not be assigned. This 30 percent rating has been in effect since August 14, 1993, however, and will not be disturbed. A higher rating for this diagnostic code is not available, as the increased ratings are based on the Veteran’s residuals. Therefore, although the 30 percent under diagnostic code 8024 will remain in place, an increase under this diagnostic code cannot be assigned. In July 2016, the Board denied a rating in excess of 30 percent for limited cervical motion. The Veteran did not appeal this decision to the Court. The cervical spine rating will remain at 30 percent and no further discussion of that residual will be included in this decision. The Veteran’s dysthymic disorder is rated 30 percent from May 17, 2010, to May 13, 2012, and is rated 50 percent thereafter; the right upper extremity radiculitis is rated 30 percent since May 17, 2010; and the Veteran’s scars are rated 10 percent since May 17, 2010. The Board’s previous denials of increases for the dysthymic disorder and scar ratings have been vacated by the Court and the right upper extremity radiculitis rating was remanded by the Board. The ratings for all three of those residuals will be discussed below. The JMPR stated that the Veteran’s lumbar spine, dizziness, and vision impairment may be residuals of his service-connected disorder and the Veteran has maintained that erectile dysfunction and headaches are residuals of his service connected disorder. Additionally, in July 2016, the Board remanded the question of whether a left upper extremity disorder was a residual of the Veteran’s service connected disorder, but a clear determination was not made. The Board is remanding these residuals as directed below for VA medical opinions as to whether they are residuals of his service connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord, or whether disorders manifested by those symptoms were caused or aggravated by the service-connected disorder and residuals. 1. Dysthymic Disorder A 30 percent evaluation for dysthymic disorder is warranted where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation requires occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation, obsessional rituals which interfere with routine activities, intermittently illogical, obscure, or irrelevant speech, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control (such as unprovoked irritability with periods of violence), spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work like setting), and an inability to establish and maintain effective relationships. A 100 percent evaluation requires total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting himself or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9433 (2017). The use of the phrase “such symptoms as,” followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant’s social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). VA treatment records from April and June 2012 indicate that the Veteran had suicidal ideation. In January 2015, the Veteran was afforded a central nervous system examination. The examiner indicated that the Veteran’s mental health disorder resulted in gross impairment in thought processes or communication. In February 2015, the Veteran was afforded a VA mental disorders examination. He reported that he had been married for 15 years, had 2 adult children, and that he attended church, had friends, and spent time watching television. He had symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, poor concentration, and fatigue; he denied suicidal and homicidal ideation. In March 2017, the Veteran was afforded another VA mental disorders examination. The Veteran reported that he was still married to his spouse, now of 17 years, but there was stress in the marriage. He reported isolating himself and that, when at home, he spent his time alone. He continued to attend church but decreased his social interactions and physical activities; he increased the time he spent watching television. He reported daily depressed mood, low energy, daily fatigue, difficulty sleeping, work-related stress, and irritability and anger. He was taking medication for his depression. On examination, he had depressed mood; anxiety; chronic sleep impairment; flattened affect; disturbances of motivation and mood; difficulty adapting to stressful circumstances, including work or a worklike setting; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. VA treatment records dated between July and October 2017 indicate that the Veteran continued to take antidepressant medication but did not notice an improvement in his symptoms. He and his spouse were still married and he reported a good relationship with his children and family. He reported a lack of interest in activities he previously enjoyed, sleep difficulty, poor appetite, fatigue, feelings of failure, difficulty concentrating, irritability, persistent worry, feeling on edge, some homicidal ideation, and suicidal ideation more than half of the days. During the period on appeal, the Veteran’s dysthymic disorder caused gross impairment in thought processes or communication, depressed mood, low energy, anxiety, chronic sleep impairment, disturbances of motivation and mood, poor concentration, fatigue, isolation, decrease in social interactions and physical activities, work-related stress, irritability and anger, flattened affect, disturbances of motivation and mood, difficulty adapting to stressful circumstances, suicidal and homicidal ideation, and an intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene. Given these facts, the Board finds that the Veteran’s symptoms most closely approximate a 70 percent rating during the entire period on appeal. See 38 C.F.R. § 4.7. A 100 percent rating is not warranted as the Veteran was not totally socially and occupationally impaired. He continued to work, had a good relationship with his children and family, attended church services, and had some friends. 2. Scars Scars of the head, face, or neck or other disfigurement of the head, face, or neck is rated according to diagnostic code 7800. A 10 percent rating is warranted for scars with one characteristic of disfigurement. A 30 percent rating is warranted for scars with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. A 50 percent rating is warranted for scars with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement. There are 5 relevant notes to diagnostic code 7800. Note (1): The 8 characteristics of disfigurement, for purposes of evaluation under § 4.118, are: 1. Scar 5 or more inches (13 or more cm.) in length. 2. Scar at least one-quarter inch (0.6 cm.) wide at widest part. 3. Surface contour of scar elevated or depressed on palpation. 4. Scar adherent to underlying tissue. 5. Skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.). 6. Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.). 7. Underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.). 8. Skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Note (2): Rate tissue loss of the auricle under diagnostic code 6207 (loss of auricle) and anatomical loss of the eye under diagnostic code 6061 (anatomical loss of both eyes) or diagnostic code 6063 (anatomical loss of one eye), as appropriate. Note (3): Take into consideration unretouched color photographs when evaluating under these criteria. Note (4): Separately evaluate disabling effects other than disfigurement that are associated with individual scar(s) of the head, face, or neck, such as pain, instability, and residuals of associated muscle or nerve injury, under the appropriate diagnostic code(s) and apply § 4.25 to combine the evaluation(s) with the evaluation assigned under this diagnostic code. Note (5): The characteristic(s) of disfigurement may be caused by one scar or by multiple scars; the characteristic(s) required to assign a particular evaluation need not be caused by a single scar in order to assign that evaluation. 38 C.F.R. § 4.118, Diagnostic Code 7800 (2017). Scars that are unstable or painful are rated according to diagnostic code 7804. Diagnostic code 7804 states that one or two scars that are unstable or painful warrants a 10 percent evaluation. Three or four scars that are unstable or painful warrants a 20 percent evaluation. Note (1) to the diagnostic code states that “An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar.” Note (2) states that “If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars.” Note (3) states: “Scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this diagnostic code, when applicable.” 38 C.F.R. § 4.118, Diagnostic Code 7804 (2017). The Veteran was afforded a VA examination for his scars in October 2010. It was noted that he had two scars from surgeries addressing his Chiari malformation disability. The examiner reported a cervical spine scar that was 17 centimeters by 0.5 centimeters, stable, and slightly elevated. There was no underlying tissue loss, inflammation, edema, induration, inflexibility, or limitation of motion caused by the scar. There were mild keloidal changes present and the scar was normally pigmented. The examiner also reported a thoracic spine scar that was 11.5 centimeters by 0.5 centimeters but widened to 1.5 centimeters, and was tender to palpation but nonadherent, slightly elevated, and stable. There was no underlying tissue loss, inflammation, edema, induration, inflexibility, or limitation of motion caused by the scar. There was moderate keloid formation throughout the scar and the scar was normally pigmented. The Veteran reported that the scars were intermittently painful and that he had difficulty turning his head when experiencing pain flare-ups in the cervical scar. Given these symptoms, the Board finds that the Veteran’s cervical spine scar is a disfiguring scar of the neck and a rating under diagnostic code 7800 is warranted. The scar was more than 13 centimeters in length and was elevated. Therefore, a 30 percent rating is warranted for two characteristics of disfigurement. See 38 C.F.R. § 4.118, Diagnostic Code 7800. A rating in excess of 10 percent for unstable or painful scars is not warranted as the Veteran has two painful scars but they are stable. See 38 C.F.R. § 4.118, Diagnostic Code 7804. 3. Right (Minor) Upper Extremity Radiculitis The Veteran’s radiculitis is rated according to diagnostic code 8513. A 20 percent rating is warranted for mild incomplete paralysis of all radicular groups of the minor upper extremity. A 30 percent rating is warranted for moderate incomplete paralysis of all radicular groups of the minor upper extremity. A 60 percent rating is warranted for severe incomplete paralysis of all radicular groups of the minor upper extremity. An 80 percent is warranted for complete paralysis of all radicular groups of the minor upper extremity. 38 C.F.R. § 4.124a, Diagnostic Code 8513 (2017). May and December 2016 VA examinations indicate that the Veteran’s right upper extremity is his minor extremity. At an August 2010 VA examination, the Veteran reported that he felt that his right arm was becoming weaker with numbness and tingling happening more frequently and with more intensity. On examination there was no muscle atrophy but there was impairment in both the monofilament light touch and vibratory sensation throughout the entire extremity. At a December 2010 VA examination, the Veteran reported weakness in the upper extremity. On examination, he had slightly decreased upper extremity strength, normal tone, full active range of motion, and decreased deep tendon reflexes. At a June 2014 VA examination, the Veteran had decreased elbow and wrist flexion and extension, decreased grip, decreased pinch, decreased reflexes, and decreased sensory and vibration sensations. The examiner indicated that the Veteran had mild right upper extremity muscle weakness and that he could carry moderate to heavy loads with his upper extremities. The examiner concluded that the Veteran’s overall impairment was moderate. In January 2015, the Veteran was afforded another VA examination. He had muscle weakness, decreased right elbow and wrist extension and flexion, decreased grip and pinch, no reflexes, and muscle atrophy in the right hand. The examiner indicated that the Veteran’s muscle weakness was mild. The report of a May 2016 VA examination indicates that the Veteran had moderate constant pain, moderate paresthesias and/or dysesthesias, moderate numbness, muscle atrophy in the hand, no reflexes, and decreased sensation. It was noted that the Veteran had carpal tunnel syndrome which was not a residual of his service connected disorder, but that it caused moderate incomplete paralysis of the median nerve. In an August 2016 addendum opinion, the examiner noted that the right upper extremity radiculitis was mild. In December 2016, the Veteran was afforded another VA examination. The Veteran had moderate constant pain, moderate paresthesias and/or dysesthesias, moderate numbness, pain in the right shoulder, paresthesias and numbness in all fingers of the right hand and in the right shoulder, decreased elbow and wrist flexion and extension, decreased grip and pinch, no reflexes, and decreased sensation. The examiner indicated that the Veteran’s carpal tunnel syndrome was not a residual of his service connected disorder, but that it caused moderate incomplete paralysis of the median nerve. In a March 2017 addendum opinion, the examiner noted that the Veteran had mild weakness and sensory loss in the right upper extremity. VA treatment records dated between February 2011 and August 2017 indicate that the Veteran had right upper extremity symptoms of decreased sensation, decreased grip strength, decreased reflexes, and muscle atrophy in the hand. During the period on appeal, the Veteran’s right (minor) upper extremity radiculitis caused weakness, moderate numbness, tingling, moderate constant pain, moderate paresthesias and/or dysesthesias, decreased strength, an absence of reflexes, decreased elbow and wrist flexion and extension, decreased grip, decreased pinch, decreased sensations, right upper extremity muscle weakness, and right hand muscle atrophy. Given these facts, the Board finds that a 60 percent rating most closely approximates the Veteran’s symptoms during the entire period. 38 C.F.R. § 4.7. See Hart v. Mansfield, 21 Vet. App. 505 (2007). An 80 percent rating is not warranted as the Veteran does not have complete paralysis of all right upper extremity radicular groups. REASONS FOR REMAND 1. A determination of whether lumbar spine complaints are a residual of the Veteran’s service-connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord is remanded. 2. A determination of whether dizziness is a residual of the Veteran’s service connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord is remanded. 3. A determination of whether blurred vision is a residual of the Veteran’s service-connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord is remanded. 4. A determination of whether headaches are a residual of the Veteran’s service-connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord is remanded. 5. A determination of whether erectile dysfunction is a residual of the Veteran’s service-connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord is remanded. 6. A determination of whether left upper extremity complaints are a residual of the Veteran’s service-connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord is remanded. The matters are REMANDED for the following action: 1. Reasons for the remand: Remand is necessary to obtain VA medical opinions as to whether lumbar spine complaints, dizziness, vision impairment, headaches, erectile dysfunction, and left upper extremity complaints are residuals of the Veteran’s service-connected disorder or whether disorders causing these symptoms were caused or aggravated by the service-connected disorder and residuals. 2. Schedule the Veteran for VA examinations to obtain an opinion as to whether lumbar spine complaints, dizziness, vision impairment, headaches, erectile dysfunction, and left upper extremity complaints are residuals of the Veteran’s service connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord or whether disorders causing these symptoms were caused or aggravated by the service-connected disorder and residuals. All indicated tests and studies should be accomplished and the findings reported in detail. All relevant medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided. The examiner should address the following: (a.) whether each of the following is a residual of the service connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord: i. Lumbar spine complaints. ii. Dizziness. iii. Vision impairment. iv. Headaches. v. Erectile dysfunction. vi. Left upper extremity complaints. (b.) whether a disorder manifested by each of the following symptoms was caused by the service connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord and its residuals: i. Lumbar spine complaints. ii. Dizziness. iii. Vision impairment. iv. Headaches. v. Erectile dysfunction. vi. Left upper extremity complaints. (c.) whether a disorder manifested by each of the following symptoms was aggravated by the service connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord and its residuals: i. Lumbar spine complaints. ii. Dizziness. iii. Vision impairment. iv. Headaches. v. Erectile dysfunction. vi. Left upper extremity complaints. The examiner’s attention is drawn to the following: *April 1994 VA examination indicating that the Veteran’s syringomyelia was diagnosed because he had constant headaches and that he continued to have headaches after his surgeries. *April 2002 VA examination where the Veteran reported continuing to have headaches two times per week. *May 2002 VA treatment record stating that the Veteran had “mild headaches [which] last a few minutes that are unchanged since his operation[s] [in] in the early 1990’s.” VBMS Entry 9/13/2016, p. 3. *January 2004 VA treatment record stating that the Veteran had increased lordosis and significant weakness of the low back. VBMS Entry 5/27/2011, p. 76. *April 2004 VA treatment record stating that the Veteran had chronic low back pain with radicular symptoms. VBMS Entry 5/27/2011, p. 70. *May 2004 VA examination report where the examiner indicated that the Veteran’s shunt placement was in both the cervical and thoracic spine. *August 2004 VA treatment record stating that the Veteran had chronic low back pain with significant spasm. VBMS Entry 5/27/2011, p. 58. *October 2006 VA examination report indicating that the Veteran had headaches and dizziness that began in 1986 which led to his diagnosis and surgeries, that he had low back complaints beginning in 1995, and that he had a work-related low back injury in 1998. He was diagnosed with a lumbar strain. *April 2007 VA MRI report indicating that the Veteran had degenerative disc disease (DDD) of the lumbar spine and degenerative stenosis involving the L5-S1 intervertebral nerve root canals. VBMS Entry 6/21/2010, p. 50. *June 2008 VA treatment record indicating that the Veteran was status-post “[C]hiari decompression with syringo subarachnoid shunt now with severe [low back pain] and [left lower extremity] pain/weakness with minimal lumbar disease.” VBMS Entry 6/21/2010, p. 34. *May 2010 VA MRI report stating that the Veteran had “persistence of syringohydromyelia of the cervical cord throughout most of its extent from C2 through upper thoracic spine.” VBMS Entry 10/20/2010. *August 2010 VA examination report indicating that the May 2010 MRI report stated that there was a “flame-shaped area of abnormal hyperintense T2 signal within the cervical cord. This extends from inferior C2 through the entirety of the cervical region to the upper thoracic T1 and T2 level.” *December 2010 VA examination where the Veteran reported bilateral upper extremity weakness and low back pain, was diagnosed with L5-S1 mild broad based disc bulge with moderate left-sided neural foraminal narrowing, and where the examiner opined that the low back pain “is as likely as not caused by or as a result of Chiari malformation or cervical laminectomies but more so by lumbar L5-S1 inter-foraminal narrowing.” *January 2011 VA addendum opinion where the examiner reiterated that the low back pain “is as likely as not caused by or as a result of Chiari malformation or cervical laminectomies but more so by lumbar L5-S1 inter-foraminal narrowing.” *February 2011 VA treatment record stating that the Veteran had impairment in light touch/pin prick sensation, decreased motor responses, and decreased reflexes in the left upper extremity. VBMS Entry 2/28/2011, p. 9. *June 2014 VA examination report stating that the Veteran had complaints of bilateral numbness to his hands, low back pain and radiation to the right lower extremity, and dizziness; that the Veteran took 3 medications for his service-connected disorder; that the Veteran had erectile dysfunction that was caused by back pain preventing him from being interested in sexual activity; that he had decreased elbow and wrist flexion and extension, decreased grip, decreased pinch, decreased reflexes, decreased response to sensory testing, and mild muscle weakness in the left upper extremity; and that he had numbness in his left hand. *January 2015 VA examination report stating that the Veteran had complaints of left upper extremity pain, took medication for his neurologic symptoms, and had no reflexes in his left upper extremity. *July 2015 VA treatment record where the Veteran reported complaints of blurred vision. VBMS Entry 9/13/2016, p. 1. *May 2016 VA examination report indicating that the Veteran had mild left upper extremity constant pain, paresthesias and/or dysesthesias, and numbness and no left upper extremity reflexes. *June 2016 VA treatment record indicating prior medical history of spinal stenosis, carpal tunnel syndrome/ulnar neuropathy, and erectile dysfunction. VBMS Entry 6/16/2016, p. 3. *June 2016 VA X-ray study of the lumbar spine indicating a diagnosis of DDD. VBMS Entry 11/21/2016, p. 28. *September 2016 VA addendum opinion stating that the Veteran had bilateral carpal tunnel syndrome. *December 2016 VA examination report indicating that the Veteran had no reflexes in his left upper extremity and had “[m]ild weakness [in the] left hand from syringomyelia,” but was otherwise normal. *March 2017 VA addendum opinion stating that no deficit was found in the left hand at the December 2016 examination. 3. Readjudicate the symptoms on appeal to determine whether they are residuals of service connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord or whether disorders manifested by those symptoms were caused or aggravated by the service-connected Chiari malformation with syringomyelia and residuals of a posterior fossa decompression and syringo subarachnoid shunt of the spinal cord. If any benefit sought on appeal remains denied, the Veteran should be provided a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response before the case is returned to the Board. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. E. Miller, Associate Counsel