Citation Nr: 19116149 Decision Date: 03/07/19 Archive Date: 03/05/19 DOCKET NO. 17-02 446 DATE: March 7, 2019 ORDER New and material evidence having been received, the claim of entitlement to service connection for residuals of a cervical hyperextension injury with cord compression is reopened. REMANDED Entitlement to service connection for residuals of a cervical hyperextension injury with cord compression is remanded. FINDINGS OF FACT 1. An unappealed September 2005 rating decision denied service connection for cervical hyperextension injury with cord compression. 2. Evidence submitted following the September 2005 rating decision, including October 2016 orthopedic consultation notes, raises a reasonable possibility of substantiating the claim. CONCLUSION OF LAW New and material evidence has been received to reopen the claim of entitlement to service connection for residuals of a cervical hyperextension injury with cord compression. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104, 3.156, 20.302 (2018). REASONS FOR REMAND The Veteran honorably served from August 1986 to July 1991, and from April 2008 to August 2008. The nature, extent and etiology of the Veteran’s in-service cervical hyperextension injury with cord compression residuals remand obscure. The October 2016 VA examiner diagnosed lumbar and cervical strain and noted pain radiating into the lower extremities and difficulty with ambulation, but ultimately concluded that the Veteran’s in-service injury resolved and that his current symptoms were unrelated to service. No real explanation was provided for the opinion outside of a vague statement pointing to 2011 as the genesis of the Veteran’s current difficulties. The examiner did not, however, appear to consider the Veteran’s statements regarding complaints of similar symptoms since service (as opposed to a much later 2011 onset). As such, the October 2016 VA opinion is inadequate. The record also includes private October 2016 orthopedic consult notes that reflect lumbar spine symptoms together with pain radiating into the bilateral hips, buttocks, and lower extremities. The private orthopedist noted the Veteran’s reports that his pain was of 28 years duration, but did not specially offer a clear opinion as to the relationship between the Veteran’s in-service cervical spine injury and his current symptoms. Given the ambiguity surrounding the extent and etiology of the Veteran’s cervical hyperextension injury residuals, an additional examination and opinion is needed on remand. Updated treatment records should also be obtained. The matters are REMANDED for the following action: 1. Obtain any updated outstanding private and/or VA treatment records relevant to the issue on appeal. 2. Schedule the Veteran for an examination with a qualified clinician (other than the clinician that performed the October 2016 VA examination) to determine the nature and etiology of the Veteran’s cervical hyperextension injury residuals. After reviewing the record and conducting an examination of the Veteran, the examiner should identify all residuals associated with the Veteran’s in-service cervical spine injury. The examiner should specifically determine whether it is at least as likely as not that the Veteran’s in-service cervical spine injury resulted in any current cervical spine, lumbar spine, bilateral hip, and/or lower extremity disability. The examiner should also specifically determine whether it is at least as likely as not that the Veteran’s in-service cervical spine injury resulted in any other neurological disability. In formulating his or her opinion(s), the examiner should specifically consider the Veteran’s complaints of pain following the in-service incident and continuing (while gradually worsening) to the present day. The complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. McKone, Law Clerk