Citation Nr: 19138709 Decision Date: 05/17/19 Archive Date: 05/17/19 DOCKET NO. 15-38 926A DATE: May 17, 2019 REMANDED Entitlement to service connection for a cervical spine disorder is remanded. REASONS FOR REMAND The Veteran had active service from June 1980 to August 1980 and from August 1986 to August 1989. The Board notes that the Veteran is service connected for disabilities arising from a February 1985 fall during a period of active duty for training (ACDUTRA) in Panama. Accordingly, that period of service has been converted to active service for purposes of disability compensation benefits administered by the Department of Veterans Affairs (VA). See 38 U.S.C. § 101 (24)(B)-(C). Entitlement to Service Connection for a Cervical Spine Disorder Is Remanded The Veteran has spondylosis of the cervical spine and a herniated disc at C5-C6. He underwent cervical discectomy, cervical arthrodesis with allograft, and instrumentation with ABC plate at C5-C6 in December 2012. He contends that that his cervical spine disorder is etiologically related to a February 1985 fall from a water tanker truck during a period of service with the Louisiana National Guard. According to the Veteran’s service personnel records, he slipped and fell at river crossing in Panama, striking his head on the bottom of a river. The Veteran suffered a severe laceration, and he was taken to the battalion medical aid station before being medically evacuated to Gorges Army Hospital. He was hospitalized for 8 days from February 13, 1985 to February 21, 1985 and discharged after the wound on his scalp had healed. In May 1985, the Louisiana National Guard determined that the Veteran’s fall occurred in the line of duty. He is service connected for multiple disabilities related to this fall, to include a traumatic brain injury, a scar of the forehead, and migraine headaches. The record includes a March 2019 Neck (Cervical Spine) Conditions Disability Benefits Questionnaire, Dr. M.L.J. concludes that it is more likely than not that the Veteran’s fall from a water tanker caused his cervical spine disorder. There are defects in this opinion, which reduce its overall probative value. First, the questionnaire indicates that Dr. M.L.J. has not reviewed the Veteran’s service treatment records. Such is not a fatal flaw. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008). However, it remains unclear as to how Dr. M.L.J. would have reconciled this finding with the report of a February 1985 x-ray, taken after the fall, indicating that views of the cervical spine was normal. There were also statements from fellow servicemen pertaining to the nature and scope of the injury. Second, Dr. M.L.J. did not provide a rationale for his opinion. See Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (“a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision . . . .”). The Veteran was afforded a VA examination in September 2013. The VA examiner concluded that it was less likely than not that the Veteran’s fall from a water tanker truck was etiologically related to his current cervical spine disability. The opinion is also inadequate as statements made by the examiner cause the Board to question the level of review that occurred. First, the opinion is based on a false factual premise. While the examiner accurately described the events in February 1985, the report states that the fall occurred in 1984. See Reonal v. Brown, 5 Vet. App. 458 (1993) (holding a medical opinion based upon an inaccurate factual premise has no probative value). Second, a September 2013 VA memorandum determined that the Veteran’s service treatment records for the period of active service from August 1986 to August 1989 were unavailable. Nonetheless, the examiner stated that the Veteran’s cervical spine was not considered disabling at his separation from active service in August 1989. It is not clear what evidence of record the examiner relied upon to reach this conclusion. See Miller v. West, 11 Vet. App. 345, 348 (1998) (holding a medical opinion is not probative without a factual predicate in the record). In light of the foregoing, the Veteran should be afforded a new VA examination. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide an examination, it must ensure that the examination is adequate). The matter is REMANDED for the following action: Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any cervical spine disorder. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including the residual of a fall from a water tanker truck in February 1985. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Douglas M. Humphrey, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.