Citation Nr: 20007155 Decision Date: 01/28/20 Archive Date: 01/28/20 DOCKET NO. 18-24 591 DATE: January 28, 2020 ORDER Entitlement to service connection for a headache condition, to include as secondary to service-connected cervical spine disability, is granted. Entitlement to a disability rating greater than 20 percent before May 4, 2018 and greater than 40 percent thereafter for cervical spine disability is denied. Entitlement to a disability rating of 40 percent, but not greater, for the period on appeal for right upper extremity radiculopathy is granted. Entitlement to a disability rating greater than 20 percent for left upper extremity radiculopathy is denied. REMANDED Entitlement to service connection for sleep apnea, to include as secondary to medication taken for service-connected cervical spine disability, is remanded. Entitlement to service connection for a low back condition is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for hypertension, claimed as “high blood pressure,” is remanded. FINDINGS OF FACT 1. The Veteran’s headaches are proximately caused by his service-connected cervical spine disability. 2. Before May 4, 2018, the Veteran’s cervical spine disability was manifested by forward flexion of the cervical spine within normal limits; total cervical spine range of motion 185 degrees; painful motion; less movement than normal; incoordination, and; impaired ability to execute skilled movements smoothly. 3. Beginning May 4, 2018, the Veteran’s cervical spine disability was manifested by unfavorable ankylosis of the entire cervical spine. 4. The Veteran’s right upper extremity radiculopathy is manifested by no more than moderate incomplete paralysis of the major extremity. 5. The Veteran’s right upper extremity radiculopathy is manifested by no more than mild incomplete paralysis of the minor extremity. CONCLUSIONS OF LAW 1. The criteria for service connection for headaches as secondary to cervical spine disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for a rating in excess of 20 percent before May 4, 2018 and in excess of 40 percent thereafter for a cervical spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5242-5243. 3. The criteria for a disability rating of 40 percent, but no more, for moderate partial paralysis of the middle radicular group, major extremity, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8511. 4. The criteria for a disability rating of 20 percent, but no more, for mild partial paralysis of the middle radicular group, minor extremity, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8511. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had service in the Army National Guard and was called to active duty from May 1995 to August 1995 and from March 2003 to August 2004. Unfortunately, the Veteran died during the pendency of this appeal. The appellant is the Veteran’s surviving spouse and she has been substituted for the Veteran. Service Connection 1. Entitlement to service connection for a headache condition, to include as secondary to service-connected cervical spine disability. The Board finds that entitlement to service connection on a secondary basis for the Veteran’s headaches is warranted. Veteran’s post-treatment medical records demonstrate a current chronic headache condition that has demonstrably worsened over time. Statements associated with the record reflect that these headaches began immediately after his June 2003 active-duty cervical injury. In June 2016 a private expert opined that it is at least as likely as not that the Veteran’s headache condition was proximately due to or aggravated beyond its natural progress by his cervical spine disability. The private expert explained that cervical spine disabilities can cause “cervicogenic headaches” such as those the Veteran experienced. This rationale was based on a review of the Veteran’s medical history, which showed complaints of headaches beginning with his cervical spine injury and often worsening at the same times. The private expert also provided medical literature supporting this rationale. There is no other competent medical opinion of record. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s headache condition was proximately due to his service-connected cervical spine disability. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for a headache condition is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. INCREASED RATING 1. Entitlement to a disability rating greater than 20 percent before May 4, 2018 and greater than 40 percent thereafter for cervical spine disability. The appellant asserts that the Veteran was entitled to a higher rating because his cervical spine disability, rated as “retrolisthesis of C4 in respect to C5, central extrusion of disk material at cervical 3-4 with indentation of the cervical cord, right with osteophyte present at C4-C5” was more severe than was recognized and compensated for by his 20 percent and 40 percent ratings. The Veteran was diagnosed with intervertebral disc syndrome (IVDS) of the cervical spine. Diagnostic Code 5243 provides that IVDS is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating IVDS Based on Incapacitating Episodes provides that a 10 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. Note 1 to Diagnostic Code 5243 provides that, for purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note 1. Under the General Rating Formula, a 10 percent rating is warranted 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 rating is warranted 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 rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Unfavorable ankylosis is defined as “a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching.” Id. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is “always” considered favorable ankylosis. Id. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent before May 4, 2018 or in excess of 40 percent thereafter for his cervical spine disability based on incapacitating episodes. Although the Veteran had IVDS the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. In fact, the record shows no bed rest prescribed by a physician for this disability at any point during the period on appeal. The preponderance of the evidence is against a rating in excess of 20 percent before May 4, 2018 for the Veteran’s cervical spine disability under the General Rating Formula criteria. VA provided an examination in April 2014 to evaluate the severity of the Veteran’s cervical spine disability. The examiner noted forward flexion to 45 degrees or greater; extension to 5 degrees with objective evidence of pain at 5 degrees; right lateral flexion to 15 degrees with pain at 10 degrees; left lateral flexion to 10 degrees with pain at 5 degrees; right lateral rotation to 60 degrees with pain at 20 degrees, and; left lateral rotation to 50 degrees with pain at 20 degrees. There was no change after three repetitions. Functional loss was present and caused by: Less movement than normal; incoordination; impaired ability to execute skilled movements smoothly, and; pain on movement. The examiner diagnosed IVDS but noted no incapacitating episodes in the previous 12 months. The Veteran stated that he felt his cervical range of motion was decreasing, he was having increased headaches and neurological symptoms (rated separately) and that his pain would flare up and wake him at night, when he would have to attempt to turn his neck to reduce symptoms. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to painful movement; less movement than normal; incoordination, and; impaired ability to execute skilled movements smoothly. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that pain would wake him at night and he would have to attempt to turn his neck to reduce the pain would not result in symptoms more nearly approximating forward flexion of the cervical spine to 15 degrees or less or favorable ankylosis of the entire cervical spine. The preponderance of the evidence is against a rating in excess of 40 percent beginning May 4, 2018 for the Veteran’s cervical spine disability under the General Rating Formula criteria. VA provided an examination in May 2018 to evaluate the severity of the Veteran’s cervical spine disability. The Veteran stated that a recent cervical spine surgery (June 2017 anterior fusion for herniated disc at C3-C4) had improved his pain. He reported sharp, stabbing, constant neck pain at 2 out of 10, with flare ups about four times per month. During flare ups the Veteran reported his pain increased to 7 out of 10 and he was unable to function, so he usually went to sleep until it was over. The Veteran’s examination was during a flare up and the examiner was unable to perform the normal range of motion testing because of pain. The examiner diagnosed IVDS but noted no incapacitating episodes in the previous 12 months. The examiner also diagnosed unfavorable ankylosis of the entire cervical spine. The highest available schedular rating for a cervical spine condition under the General Rating Formula is 40 percent for unfavorable ankylosis of the entire cervical spine. While a 100 percent rating is available for unfavorable ankylosis of the entire spine, only the Veteran’s cervical spine disability is service-connected. Furthermore, the Veteran’s medical records do not show that he had unfavorable ankylosis of the entire spine. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent before May 4, 2018 and in excess of 40 percent thereafter for a cervical spine disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 4.3, 4.7 (2018). 2. Entitlement to a disability rating greater than 40 percent before May 4, 2018 and greater than 20 percent thereafter for right upper extremity radiculopathy The appellant asserts that the Veteran was entitled to a rating in excess of 40 percent before May 4, 2018 and in excess of 20 percent thereafter because his right upper extremity radiculopathy was more severe than was recognized and compensated by his original disability ratings. Paralysis of the upper radicular group is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8510. Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8610 and 8710. Under these criteria, mild incomplete paralysis is rated as 20 percent disabling for both the major and minor extremity. Moderate incomplete paralysis is rated as 40 percent for the major extremity and 30 percent for the minor extremity. Severe incomplete paralysis is rated as 50 percent for the major extremity and 40 percent for the minor extremity. Complete paralysis, with all shoulder and elbow movements lost or severely affected, hand and wrist movements not affected is rated as 70 percent for the major extremity and 60 percent for the minor extremity. 38 C.F.R. § 4.124a. Paralysis of the middle radicular group is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8511. Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8611 and 8711. Under these criteria, mild incomplete paralysis is rated as 20 percent disabling for both the major and minor extremity. Moderate incomplete paralysis is rated as 40 percent for the major extremity and 30 percent for the minor extremity. Severe incomplete paralysis is rated as 50 percent for the major extremity and 40 percent for the minor extremity. Complete paralysis, with adduction, abduction and rotation of arm, flexion of elbow, and extension of wrist lost or severely affected, is rated as 70 percent for the major extremity and 60 percent for the minor extremity. 38 C.F.R. § 4.124a. The Veteran was right handed. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). VA provided examinations in April 2014 and May 2018 to evaluate the severity of the Veteran’s upper extremity radiculopathy. Regarding impairment of motor functions, the April 2014 examination showed normal strength (5/5) in the right elbow, wrist, and fingers for all tested movements. The May 2018 examination showed reduced strength (4/5 – active movement against some resistance) in the right elbow on extension and in the right fingers on abduction. Strength testing was otherwise normal. No trophic changes were noted in either examination. Regarding sensory disturbance, the April 2014 examination showed sensation for light touch as normal in the right shoulder, decreased in the right forearm, and absent in the right hand and fingers. “Moderate” paresthesias and/or dysesthesias, and “moderate” numbness were observed in the right upper extremity. The May 2018 examination showed normal sensation to light touch in all tested areas. “Mild” paresthesias and/or dysesthesias were observed in the right upper extremity. Regarding loss of reflexes, both examinations showed normal reflexes (+2) in all areas tested. Regarding pain, the April 2014 examination showed intermittent “moderate” pain in the right upper extremity, while the May 2018 examination showed constant “moderate” pain. No muscle atrophy or complete paralysis of a nerve group was observed in either examination. The April 2014 examiner noted involvement of the upper radicular group (C5/C6 nerve roots) and the middle radicular group (C7 nerve roots), assessing the overall severity of this radiculopathy as “moderate.” The May 2018 examiner noted involvement of only the upper radicular group and assessed it as “mild.” The Veteran’s right upper extremity radiculopathy was originally rated under diagnostic code 8516 for partial paralysis of the ulnar nerve. In June 2018, without providing a rationale, the regional office (RO) changed this to diagnostic code 8510 for partial paralysis of the upper radicular group and increased the Veteran’s disability rating to 40 percent for the period before the May 2018 VA examination. The Board notes that while the April 2014 examiner indicated involvement of both the middle and upper radicular groups, and the May 2018 examiner only indicated involvement of the upper radicular group, the evidence in each examination showed symptoms affecting the middle radicular group, not the upper radicular group. While some of the symptoms noted could also be rated based on involvement of the ulnar nerve, the 40 percent rating for moderate partial paralysis of the middle radicular group of the major extremity is a greater benefit for the appellant than the 30 percent rating for moderate partial paralysis of the ulnar nerve of the major extremity. The Board will therefore rate the Veteran’s right upper extremity disability under diagnostic code 8511 for partial paralysis of the middle radicular group. Based on the above, the Board finds that both before and after the May 2018 examination, the Veteran’s disability was primarily manifest by sensory disturbance and pain, wholly sensory symptoms. The Board also finds that the most probative evidence of record is against a finding that the disability was manifest by impairment of motor functions, trophic changes, loss of reflexes, muscle atrophy, or complete paralysis. The Board thus finds that the level of impairment is at most analogous to moderate incomplete paralysis. While the May 2018 examination did show some evidence of improvement, it did not establish that this was a permanent improvement. In conclusion, the Board finds that the preponderance of the evidence shows a moderate partial paralysis of the middle radicular group for the period on appeal. This supports a 40 percent rating, but no more, for the period on appeal. In denying a rating over 40 percent, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 4.3, 4.7 (2018). 3. Entitlement to a disability rating greater than 20 percent for left upper extremity radiculopathy The appellant asserts that the Veteran was entitled to a rating in excess of 20 percent for left upper extremity radiculopathy because his disability more severe than was recognized and compensated by his original disability ratings. Paralysis of the upper radicular group is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8510. Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8610 and 8710. Under these criteria, mild incomplete paralysis is rated as 20 percent disabling for both the major and minor extremity. Moderate incomplete paralysis is rated as 40 percent for the major extremity and 30 percent for the minor extremity. Severe incomplete paralysis is rated as 50 percent for the major extremity and 40 percent for the minor extremity. Complete paralysis, with all shoulder and elbow movements lost or severely affected, hand and wrist movements not affected is rated as 70 percent for the major extremity and 60 percent for the minor extremity. 38 C.F.R. § 4.124a. Paralysis of the middle radicular group is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8511. Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8611 and 8711. Under these criteria, mild incomplete paralysis is rated as 20 percent disabling for both the major and minor extremity. Moderate incomplete paralysis is rated as 40 percent for the major extremity and 30 percent for the minor extremity. Severe incomplete paralysis is rated as 50 percent for the major extremity and 40 percent for the minor extremity. Complete paralysis, with adduction, abduction and rotation of arm, flexion of elbow, and extension of wrist lost or severely affected, is rated as 70 percent for the major extremity and 60 percent for the minor extremity. 38 C.F.R. § 4.124a. The Veteran was right handed. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). VA provided examinations in April 2014 and May 2018 to evaluate the severity of the Veteran’s upper extremity radiculopathy. Regarding impairment of motor functions, the April 2014 examination showed slightly reduced strength (4/5 – active movement against some resistance) in the left elbow, wrist, and fingers for all tested movements. However, the examiner noted that the reduced strength was caused by recent left shoulder surgery, not by cervical spine related radicular issues. The May 2018 examination showed reduced strength (4/5 – active movement against some resistance) only in the left elbow on extension. Strength testing was otherwise normal. No trophic changes were noted in either examination. Regarding sensory disturbance, the April 2014 examination showed sensation for light touch as normal in the left shoulder, decreased in the left forearm, and absent in the left hand and fingers. “Moderate” paresthesias and/or dysesthesias, and “moderate” numbness were observed in the left upper extremity. The May 2018 examination showed normal sensation to light touch in all tested areas. “Mild” paresthesias and/or d were observed in the left upper extremity. Regarding loss of reflexes, both examinations showed normal reflexes (+2) in all areas tested. Regarding pain, the April 2014 examination showed intermittent “mild” pain in the left upper extremity, while the May 2018 examination showed constant “moderate” pain. No muscle atrophy or complete paralysis of a nerve group was observed in either examination. The April 2014 examiner noted involvement of the upper radicular group (C5/C6 nerve roots) and the middle radicular group (C7 nerve roots), assessing the overall severity of this radiculopathy as “mild.” The May 2018 examiner noted involvement of only the upper radicular group and assessed it as “mild.” The Veteran’s left upper extremity radiculopathy was originally rated under diagnostic code 8716 for neuralgia of the ulnar nerve. In June 2018, without providing a rationale, the regional office (RO) changed this to diagnostic code 8510 for partial paralysis of the upper radicular group and increased the Veteran’s disability rating from 10 percent to 20 percent beginning in February 2014. The Board notes that while the April 2014 examiner indicated involvement of both the middle and upper radicular groups, and the May 2018 examiner only indicated involvement of the upper radicular group, the evidence in each examination showed symptoms affecting the middle radicular group, not the upper radicular group. While some of the symptoms noted could also be rated based on involvement of the ulnar nerve, the 20 percent rating for mild partial paralysis of the middle radicular group of the minor extremity is a greater benefit for the appellant than the 10 percent rating for mild neuralgia of the ulnar nerve of the minor extremity. The Board will therefore rate the Veteran’s left upper extremity disability under diagnostic code 8511 for partial paralysis of the middle radicular group. Based on the above, the Board finds that for the period on appeal the Veteran’s disability was primarily manifest by sensory disturbance and pain, wholly sensory symptoms. The Board also finds that the most probative evidence of record is against a finding that the disability was manifest by impairment of motor functions, trophic changes, loss of reflexes, muscle atrophy, or complete paralysis. The Board thus finds that the level of impairment can be at most analogous to moderate incomplete paralysis. The preponderance of the evidence shows that the Veteran’s left middle radicular nerve root group was mildly partially paralyzed, rather than moderately. In conclusion, the Board finds that the preponderance of the evidence shows a mild partial paralysis of the middle radicular group for the period on appeal. This supports a 20 percent rating, but no more, for the period on appeal. In denying a rating over 20 percent, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea, to include as secondary to service-connected cervical spine disability. The appellant submitted a March 2019 medical opinion authored by Dr. Skaggs finding that the Veteran's service-connected cervical spine disorder "aided in the development of and permanently aggravated his obstructive sleep apnea" due to the hydrocodone prescribed to treat the pain of his disability. The Board finds the March 2019 DBQ and medical opinion are not sufficient to make an informed decision, in part because they do not identify a medical baseline by which to establish aggravation for purposes of satisfying the criteria for secondary service connection under VA law. See 38 C.F.R. § 3.310(providing, in part, that aggravation will not be established without medical evidence of a baseline level of severity of the claimed nonservice-connected condition). As the March 2019 private opinion indicates that the Veteran's obstructive sleep apnea may be secondary to his service-connected cervical spine disorder and its medications, a VA medical opinion on this issue is warranted. 38 C.F.R. § 3.159 (c). The appellant, of course, may also submit additional evidence on this issue, if she wishes. 2. Entitlement to service connection for a low back condition is remanded. 3. Entitlement to service connection for tinnitus is remanded. 4. Entitlement to service connection for hypertension, claimed as “high blood pressure,” is remanded. The Veteran’s entire universe of service treatment records has unfortunately not been associated with the claims file. See i.e. January 2008 VA Formal Finding of Unavailability. In these circumstances, when a Veteran's STRs are unavailable through no fault of his own, VA's duties to assist, to provide reasons and bases for its findings and conclusions, and to consider carefully the benefit-of-the-doubt rule are heightened. Milostan v. Brown, 4 Vet. App. 250, 252 (1993). Thus, the combination of the Veteran and the appellant’s contentions that he has suffered low back, tinnitus and high blood pressure conditions since service and the lack of STRs meet the low bar set by McLendon v. Nicholson, 20 Vet. App. 79 (2006) and the Board finds that a remand for VA medical opinions to address the nature and etiology of any tinnitus, low back and high blood pressure conditions is warranted. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4). The matters are REMANDED for the following action: 1. Obtain a medical opinion as to whether it is at least as likely as not (50% probability or more) that the Veteran's obstructive sleep apnea was caused or aggravated by his service-connected cervical spine disorder, to include a discussion regarding the pain medication prescribed to address this disability and the positive opinion rendered by Dr. Homer Skaggs in his March 2019 report. In addressing the issue of aggravation, the examiner must determine whether a baseline level of severity may be identified by which to establish the fact of aggravation. 2. Obtain a medical opinion from an appropriate clinician to determine the nature and etiology of any - low back disability; AND - tinnitus disability; AND - high blood pressure/hypertension disability; - of the Veteran before his death. - The examiner must opine whether the disabilities were at least as likely as not related to an in-service injury, event, or disease - Regarding his low back claim, the examiner is directed to discuss the June 2003 impact injury that caused his service-connected cervical spine disability. For any disability diagnosed, including arthritis, they must opine whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. The examiner must also opine whether any diagnosed disability was at least as likely as not (1) proximately due to, or (2) aggravated beyond its natural progression by any service-connected disability or disabilities. 3. Readjudicate the Veteran’s claims. M.J. COLICELLI Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Zimmerman 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.