Citation Nr: 19123792 Decision Date: 03/29/19 Archive Date: 03/29/19 DOCKET NO. 17-55 495 DATE: March 29, 2019 ORDER Entitlement to service connection for bilateral lower extremity peripheral neuropathy as secondary to service-connected lumbar and lower thoracic spine disability is denied. FINDING OF FACT The preponderance of the competent evidence is against finding that the Veteran’s bilateral peripheral neuropathy was caused or aggravated by his service-connected lumbar and lower thoracic spine disability. CONCLUSION OF LAW The criteria for service connection for bilateral lower extremity peripheral neuropathy are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1968 to December 1971. Service Connection for Bilateral Lower Extremity Peripheral Neuropathy Service connection may be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. See 38 C.F.R. § 3.310(b); Allen v. Brown, 8 Vet. App. 374 (1995). The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012); Kahana, 24 Vet. App. at 433-34. A Veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Id. at 1287 (quoting 38 U.S.C. § 5107 (b)). Here, the Veteran specifically indicates that his bilateral lower extremity peripheral neuropathy was caused by his service-connected lumbar and lower thoracic spine disability. The Veteran is currently diagnosed with bilateral lower extremity peripheral neuropathy. See e.g., VA and private treatment records beginning in 2014. The Board notes that a May 2017 VA examination report noted that there was no evidence of lower extremity neuropathy and that EMG in July 2014 showed no nerve abnormalities. Nevertheless, given the extensive evidence of a current diagnosis, the Board assigns no probative weight to the May 2017 VA examiner’s conclusion. Based on the reasons and bases expressed below, the Board concludes that the preponderance of the evidence is against finding that the bilateral peripheral neuropathy is related to the service-connected lower thoracic and lumbar spine disability with associated left lower extremity radiculopathy. According to November 1991 private treatment records, the Veteran had a left L-4, 5, and L-5 S-1 radicular neuropathy. Later in November 1991, the Veteran complained of 25 percent back pain and 75 percent left leg pain. He indicated that the symptoms were present since June 1991 with predominance leg pain in October 1991 with weakness of the left ankle and numbness in the left foot. Subsequent to the lumbar exploration and decompression, it was noted that the Veteran’s left leg pain was relieved and weakness in the left foot was improving. During a February 2006 VA spine examination, the VA examiner noted a diagnosis of peripheral neuropathy, but indicated that this was incidental finding, which was not requested as part of the examination report. Thereafter, during an October 2013 VA back examination, it was noted that the Veteran’s sensory symptoms were attributed to incidental diagnosis of idiopathic peripheral neuropathy, which was unrelated to his back condition. In an October 2013 statement in support of claim, the Veteran indicated that since his back surgery in 1991 he lost feeling in his feet and the loss of feeling extended to his legs. According to private treatment records dated in September 2014, the Veteran sought treatment for lower extremity weakness and instability related to peripheral neuropathy and lumbar radiculopathy. The diagnosis was peripheral neuropathy – “etiology to be determined.” According to August 2015 VA treatment records, the Veteran was diagnosed by the Mayo Clinic with length dependent sensory motor peripheral neuropathy. The medical professional indicated that as part of the Veteran’s evaluation, he had an EMG that revealed axonal demyelinating length-dependent peripheral neuropathy and chronic L5-S1 left lumbar radiculopathy. MRI showed significant foraminal stenosis at L4-L5 and L5-S1, worse on the left, and the sural nerve biopsy showed signs of demyelination and axonal degeneration. It was further noted that the Veteran had a brother and a cousin with peripheral neuropathy. In a January 2016 letter authored by the Veteran’s chiropractor, it was noted that he had an ongoing lumbar neuropathy and indicated that the purpose of the letter was to assist the Veteran with covering the costs of his current and future care associated with his service-connected disability. In April 2016, the Veteran underwent a VA examination for peripheral nerve conditions, at which time the VA examiner confirmed a diagnosis of length-dependent diffuse sensorimotor peripheral neuropathy, likely inherited. The VA examiner opined that it was less likely than not that the Veteran’s peripheral neuropathy was related to his service-connected back disability, to include enthesopathy arthropathy. The VA examiner explained that the Veteran had an extensive workup at the Mayo Clinic in 2014 and 2015 that included a MRI, neurology consult, neurosurgery consult, sural nerve biopsy, and EMG/NCS tests, bilaterally. The results showed that he had chronic stable left L5-S1 radiculopathy that was at least as likely as not due to his service-connected back condition. He was also diagnosed with bilateral progressive sensory-motor mixed axonal-demyelinating peripheral neuropathy, likely inherited. The VA examiner further noted that the Veteran had two EMGs, one in 2014 and one in 2015, which showed significant progression of the peripheral neuropathy, but stable left L5-S1 radiculopathy. The peripheral neuropathy was believed to be inherited since the Veteran had family members who were also diagnosed with peripheral neuropathy in their 60s, who were not diagnosed with diabetes. The VA examiner further opined that there was no evidence that the Veteran’s leg condition was aggravated beyond natural progression by the service-connected back disability. The VA examiner explained that the EMG/NCS in 2012 showed stable chronic radiculopathy and progressive severe chronic peripheral neuropathy that was believed to be hereditary, since the Veteran had two brothers who also were diagnosed with peripheral neuropathy. Regarding the Veteran’s baseline status of the legs, the VA examiner noted that there was no reliable evidence or documentation of the baseline of the disability other than the stable nonprogressive radiculopathy and unstable progressive peripheral neuropathy with associated weakness of the lefts and sensory symptoms of numbness and tingling. According to September 2016 VA treatment records, the Veteran and his spouse were frustrated that his neuropathy was not service-connected. The medical professional stated that they were aware this was not a determination he could help them with, and noted that the Veteran had a brother with neuropathy as well. The diagnosis showed idiopathic progressive neuropathy, sensory and motor. A review of private treatment records dated from 2014 to 2017 showed continued treatment for peripheral neuropathy, noted that the Veteran had three brothers with the same diagnosis unrelated to diabetes, and a sister with a diagnosis of diabetes and peripheral neuropathy. The assessment March 2017 was idiopathic peripheral neuropathy and the diagnosis showed hereditary motor and sensory neuropathy. In a July 2017 letter to the Veteran, his treating chiropractor noted that low back injuries commonly caused long standing peripheral nerve issues. It was further noted that these nerves also provided motor and sensory function to the lower extremities and trauma to the spine could also accelerate degeneration in adjacent spinal levels. The chiropractor added, “As far as proving that it did not happen from the injury I would think there are similar difficulties there as with proving that it did. Although the timing seems suspect as you did not have the extremity symptoms prior to the injury and subsequent surgery.” The chiropractor attached medical articles found by a search on Google Scholar that supported a correlation between lumbar laminectomy and peripheral neuropathy. In an additional July 2017 letter, the Veteran’s chiropractor stated that in his twenty-two years of clinical experienced, he saw many cases similar to that of the Veteran, and opined that his ongoing symptoms of peripheral neuropathy were related to the injuries he sustained and the failure of the surgery to correct these issues. In an August 2017 letter authored by a physician, it was noted that the Veteran asked whether there was any research that would show that injuries to L4 and L5 could result in symptoms of peripheral neuropathy, for which the answer was in the affirmative. The physician further stated that it as not possible to prove that the peripheral neuropathy was not related to the in-service injury because immediately after the surgery in 1991 the Veteran lost feelings in his feet. The physician attached medical articles in support of this statement. In September 2017, the Veteran submitted additional internet articles regarding the relationship between health-related quality of life, pain, and functional disability in neuropathic pain patients with failed back surgery syndrome. In February 2018, the Veteran underwent an additional VA examination for peripheral nerves. The VA examiner discussed the history of the Veteran’s peripheral neuropathy as well as current medical literature. It was further noted that the Veteran and his spouse did online research on the Mayo Clinic website and found out that a physician there was doing research on postsurgical failed back surgery and requested to be seen by this physician. They were told that he had “idiopathic without known cause neuropathy and no treatment available.” They added that three different chiropractors told them that there was strong evidence to support that his peripheral neuropathy was due to military back injury in July 1971 and subsequent back surgery in November 1991. According to the Veteran’s spouse, regarding a correlation to a familiar neuropathy, none of the relatives with neuropathy had it as bad or had to have a back surgery, and all were able to walk into their 80’s. After an extensive review of all the evidence, the VA examiner opined that the Veteran’s peripheral neuropathy was less likely than not related to his back condition. The VA examiner explained that neurosurgery consult in 2015 and neurology evaluation in 2018 showed that the right lower extremity neuropathy complaints were due to length dependent peripheral neuropathy based on family history, likely inherited. The examiner indicated that this was not definitive, since there was no genetic diagnosis, so instead he was diagnosed with idiopathic, without a known cause. The Veteran declined formal genetic testing. The VA examiner further noted that the only radicular complaints were in the left lower extremity not the right. After review of all the evidence, lay and medical, the Board assigns lower probative weight to the opinions rendered by the Veteran’s chiropractors and physician in comparison to the April 2016 and February 2018 VA examiners’ opinions. Notably, in all the positive opinions, there was no mentioning of the fact that more than one immediate family member had a diagnosis of peripheral neuropathy or that any medical professional who diagnosed and treated the Veteran’s peripheral neuropathy concluded that it was idiopathic, but likely inherited. More importantly, at least one of the Veteran’s chiropractors confirmed a diagnosis of hereditary peripheral neuropathy. On the contrary, both the April 2016 and February 2018 VA examiners reviewed all the medical evidence and explained that given the Veteran’s history and diagnosis, his peripheral neuropathy was not related to his in-service back injury or subsequent lumbar spine surgery in 1991. Furthermore, the Board notes that the Veteran made references to a failed back surgery syndrome; however, as noted above, immediately following the surgery, it was noted that his left leg pain was relieved and weakness in the left foot was improving. The Board finds these medical opinions highly probative because they not only contained a clear conclusion with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Additionally, regarding the news and medical literature articles submitted by the Veteran, the Court has held that “generally, an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise is too general and inconclusive.” Mattern v. West, 12 Vet. App. 222, 228 (1999) (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)). Medical treatise evidence may indicate enough of a basis of a generic relationship to establish “a plausible causality based on objective facts.” Mattern, 12 Vet. App. at 228 (citing Wallin v. West, 11 Vet. App. 509, 514 (1998)). In the present case, the medical articles are of little probative value because no medical expert has opined regarding such a nexus in this particular Veteran. This general article citing relationships between disorders is of much less probative value than the specific examination findings and diagnostic assessments of record in this case that show evidence that supports the claimed nexus. The articles, which discuss a failed back surgery, are outweighed by the medical evidence, and VA examination reports and opinions that were case specific, and provided opinions with rationale based on the facts of this case, specifically in consideration of the Veteran’s family history of peripheral neuropathy. In this regard, the Board finds that the Veteran’s spouse’s indication that his peripheral neuropathy could not have been related to genetics because other family members’ condition was not as a severe is irrelevant and of no probative value. As a layperson, she is not competent to provide evidence of an etiological nexus between the current peripheral neuropathy and his service-connected lumbar spine disability. Such etiological evidence is only competent to the extent that it relies on observable symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007). In this case, the Veteran and his spouse are competent to report that he experienced symptoms of peripheral neuropathy, but they are not competent to state that those symptoms are related to a specific diagnosis or to his service-connected lumbar spine disability or surgery. Under the facts of this case, neither the Veteran nor his spouse have been shown to have the requisite medical training to render an opinion regarding the etiology of peripheral neuropathy. Consequently, the Board gives more probative weight to the competent medical evidence discussed above. Lastly, the Board notes that the Veteran is in receipt of a separate 60 percent rating for left lower extremity lumbar radiculopathy of the sciatic nerve and a separate 20 percent rating for left lower extremity lumbar radiculopathy of the femoral nerve, both which contemplate his symptoms in the left lower extremity. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for bilateral lower extremity peripheral neuropathy and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. JAMES G. REINHART Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Yaffe, Associate Counsel