Citation Nr: 20008348 Decision Date: 01/31/20 Archive Date: 01/31/20 DOCKET NO. 16-63 905 DATE: January 31, 2020 REMANDED Entitlement to service connection for traumatic brain injury (TBI), to include residuals of headaches, blurred vision, dizziness, and a cervical disorder, is remanded. REASONS FOR REMAND The Veteran had active service from March 1966 to February 1968, November 1968 to December 1970, and November 1990 to June 1991. This matter comes before the Board of Veteran’s Appeals (Board) on appeal from a November 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Newnan, Georgia. In October 2019, the Veteran testified at a Board hearing conducted by a Veterans Law Judge who is no longer employed by the Board. A transcript of the hearing has been associated with the Veteran’s VA claims file. On December 18, 2019, the Board sent notice to the Veteran that the Judge who conducted his Board hearing was no longer employed by the Board and in accordance with 38 C.F.R. § 19.3(b) afforded the Veteran an additional opportunity to have a hearing before another Veterans Law Judge. No response was received by the Board. 1. TBI to include residuals of headaches, blurred vision, dizziness, and cervical spine disorder is remanded. In this case, the Veteran contends he is entitled to service connection for a traumatic brain injury (TBI) he suffered after a HUMVEE he was riding in hit a depression in the road and his head struck the roof of the vehicle. The Veteran was afforded a VA examination for residuals of a TBI in October 2015. The examiner diagnosed the Veteran with a TBI. Symptoms of the TBI include: complaints of mild memory loss, occasionally inappropriate social interactions, and mildly slowed motor activity due to apraxia. There is no evidence of residuals of a TBI to include migraine headaches or Meniere’s disease, although during the Veteran’s hearing, he testified he experiences severe headaches, blurred vision, and dizziness. The Veteran is currently not service connected for headaches. Therefore, the Board finds adequate evidence of a current disability. The Veteran stated in his examination that while deployed during Operation Desert Storm in 1991, he was a passenger in a soft skin HUMVEE. While riding, the vehicle hit a depression in the road and his head struck the roof. He stated he was not wearing a seatbelt or his helmet. As noted above, the Veteran was afforded a hearing before a Veterans Law Judge in October 2019. During Veteran’s testimony, he described that he could “hear a crunch in his neck” and he recalls being “dazed or unconscious.” The Veteran’s service treatment records (STR) contain a medical note discussing a head and neck injury and a diagnosis of a concussion. The Board finds the Veteran competent and credible to discuss his symptoms and experiences while deployed. Given the corroborating evidence of a head and neck injury in the Veteran’s STR and his testimony, the Board finds adequate evidence of an in-service event or injury. The examiner opined the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service event or injury. Although the examiner stated it is least likely as not that the Veteran meets the criteria for a TBI in 1991 due to receiving a concussion from when his head struck the roof of the vehicle, he recovered from that injury and the impact appears to have settled in his neck. The examiner provided that the Veteran did have a concussion but the main impact of the pressure from striking the roof would invariably go to his neck where most of his complaints are. The Veteran underwent an MRI during his VA examination. There is no evidence of brain atrophy, however, his neck X-rays and MRI show evidence of a possible impaction. Specifically, the MRI was read to show multilevel degenerative disc disease (DDD) and his headaches may appear to be related to DDD. Therefore, the physical force of the impact ended up affecting his neck resulting in headaches, and on occasion numbness and tingling in his upper extremities. It was the opinion of the examiner that he would look more extensively at the exam of his neck and how the force of the impact resulted in pathology to his neck and caused associated problems. The Board finds this medical opinion to be incomplete in nature, especially in view of the evidence of record reflecting the existence of other potential residuals of TBI such as headaches, blurred vision, dizziness, and a cervical spine disorder. Therefore, the Board finds a remand is necessary in order to obtain a new examination and etiological opinion regarding these additional residuals. See 38 C.F.R. § 3.310. In this regard, the Board notes that in the case of Clemons v. Shinseki, 23 Vet. App. 1, 5-8 (2009), it was held that a claim is not necessarily limited in scope to a single or particular diagnosis and should be construed based on the reasonable expectations of the non-expert, self-represented claimant, and the evidence developed in processing that claim. Id. at 5. Essentially, the Court found that the scope of a claim cannot be limited by the terminology used by the lay Veteran, and instead must include any disability reasonably encompassed by (1) the description of the claim, (2) the described symptoms, and (3) any other relevant evidence of record. Id. In this case, the examiner describes how the TBI may have residuals to include a neck condition or the accident in the HUMVEE may have caused a neck injury that results in notable symptoms the Veteran current experiences. It is also not clear whether he fully considered the Veteran’s assertion of the additional continuing residuals of headaches, blurred vision, and dizziness. Therefore, a remand is necessary for additional development. The matters are REMANDED for the following actions: Schedule the Veteran for an additional VA examination to determine the nature and severity of the Veteran’s TBI and residuals, to include headaches, blurred vision, dizziness, and a cervical spine disorder. The examiner should provide the following information: Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s TBI and residuals, to include headaches, blurred vision, dizziness, and a cervical spine disorder, are related to his active military service, to include his HUMVEE accident. The examiner should review the claims file, conduct any tests or studies her or she deems appropriate address the Veteran’s testimony before the Veteran’s Law Judge, and lay statements provided. The examiner should also address previous findings that noted multilevel degenerative disc disease in the cervical spine. The examiner shall provide a complete rationale for any opinions offered. If the examiner is unable to provide any requested opinion without resort to speculation, he or she should explain why this is so. The examiner should set forth all examination findings, with a clear rationale for the conclusions reached. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher J. DeBoer, 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.