Citation Nr: 20023944 Decision Date: 04/07/20 Archive Date: 04/07/20 DOCKET NO. 17-48 831 DATE: April 7, 2020 REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for headaches, to include as secondary to a neck disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1972 to August 1974. The matters come before the Board of Veterans’ Appeals (Board) on appeal from a February 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In January 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A copy of the proceeding is associated with the electronic claims file. Service Connection for a Back and Neck Disability The Veteran contends that his back and neck disabilities are due to an in-service February 1974 motor vehicle accident. The service treatment records indicate that on February 17, 1974, the Veteran reported experiencing upper back pain. The physician indicated that the X-rays of the thoracic spine were normal and diagnosed the Veteran with neuro muscular sprain. On February 28, 1974, the Veteran reported experiencing neck pain for the past two weeks. He was diagnosed with neck strain. On March 5, 1974, the Veteran reported that his neck pain had gone away but that he continued to have pain in the thoracic area. The physician diagnosed him with back ache. The Veteran’s August 1974 separation examination noted no spine or other musculoskeletal abnormalities. The Veteran was afforded a VA examination in January 2015, in which he reported experiencing neck and back pain since his 1974 motor vehicle accident. The VA examiner indicated that the Veteran did not have a cervical spine condition, as there was no evidence to support a diagnosis for the claimed condition. The examiner further indicated that a medical treatment note from the time of the 1974 motor vehicle accident indicated that he had a cervical sprain and his X-ray was normal. The examiner concluded that there was no evidence of an ongoing neck condition. Regarding the Veteran’s back disability, the Veteran was diagnosed with an old T12 compression fracture. Upon examination, the examiner noted that the lumbar spine was normal. The examiner opined that the Veteran’s back disability was less likely than not incurred in or caused by the 1974 motor vehicle accident. She reasoned there was no evidence of treatment history linking his current condition to the motor vehicle accident that occurred approximately 40 years prior. In February 2016, the Veteran submitted private disability benefit questionnaires (DBQs) for his neck and back conditions that were completed by Dr. O.S. The Veteran reported experiencing neck and back pain since the February 1974 motor vehicle accident. Dr. O.S. diagnosed the Veteran was cervical spondylosis, mechanical back pain syndrome, degenerative disc disease of the thoracolumbar spine, intervertebral disc syndrome of the thoracolumbar spine, and vertebral fracture (vertebrae of the back). In February 2018, the Veteran submitted a private medical opinion from Dr. O.S., who opined that the Veteran’s current disabilities are those of an old injury from a traumatic impact, consistent with his documented 1974 motor vehicle accident. No further rationale or explanation was provided for this statement. The Board finds that remand is required for an adequate VA examination and medical opinion. Where VA provides a veteran with an examination in a service connection claim, the examination and medical opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Here, the January 2015 VA medical opinion regarding the Veteran’s back disability is inadequate as the examiner relied upon lack of documented continuity of medical care, rather than symptoms, in rendering the opinion. In this regard, the non-documentation of chronicity of care after the Veteran’s in-service injury is insufficient rationale to support a negative opinion in light of his reports of continuity of symptomology since service. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (noting that most of the probative value of a medical opinion comes from its reasoning); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that it is incumbent on the examiner to consider all of the relevant evidence before forming an opinion). Moreover, as the February 2016 private DBQ indicated that the Veteran has a current neck condition, the Board finds that remand is necessary in order to obtain an adequate VA examination and medical opinion as to whether the Veteran’s neck disability is etiologically related to service. Service Connection for Headaches The Veteran contends that his headaches are attributable to his 1974 motor vehicle accident. Specifically, he contends that he has experienced headaches continuously since service. See January 2020 hearing transcript. A January 2015 VA examiner noted that the Veteran did not have a headache condition. In February 2016, the Veteran submitted a private DBQ completed by Dr. O.S., who diagnosed the Veteran with headaches due to cervical spondylosis/chronic neck pain. No rationale or explanation was provided for this opinion. The Board finds that the Veteran is competent to speak to manifestations or symptoms of migraines or headaches. Thus, the Veteran should be afforded another VA examination to determine the nature and etiology of his headaches. Additionally, as the February 2016 DBQ raised the issue of secondary service connection, a VA medical opinion should be obtained as to whether the Veteran’s headaches were caused by or aggravated by his claimed neck disability. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Thereafter, schedule the Veteran for a VA examination with an appropriate medical professional to determine the nature and etiology of his back and neck disabilities. All necessary diagnostic testing and evaluation should be performed, and all findings set forth in detail. Following a review of the claims file, the examiner is to provide an opinion as to the following: a. Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s diagnosed back disorder manifested in or is otherwise etiologically related to service, to include the February 1974 motor vehicle accident; b. Is it at least as likely as not that the Veteran’s diagnosed neck disorder manifested in or is otherwise etiologically related to service, to include the February 1974 motor vehicle accident. In addressing the above questions, the examiner should address and discuss the submitted February 2018 private medical opinion from Dr. O.S., which stated that the Veteran’s current disabilities are those of an old injury from a traumatic impact, consistent with his documented 1974 motor vehicle accident. The examiner is further reminded that the Veteran’s lay statements as to onset and continuity of symptoms must be considered and weighed in making the determination as to whether a nexus exists between the Veteran’s neck and back disabilities and his military service. A complete rationale must be provided for all opinions expressed. If an opinion cannot be offered without resort to mere speculation, the examiner must indicate why this is the case and what additional evidence, if any, would allow for a more definitive opinion. 3. After completing directive #1, schedule the Veteran for a VA examination with an appropriate medical professional to determine the nature and etiology of the Veteran’s headaches. All necessary diagnostic testing and evaluation should be performed, and all findings set forth in detail. Following a review of the claims file, the examiner is to provide an opinion as to the following: a. Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s headaches manifested in or are otherwise etiologically related to service, the include the February 1974 motor vehicle accident; b. Is it at least as likely as not that the Veteran’s headaches were caused by his neck disability; c. Is it at least as likely as not that the Veteran’s headaches are aggravated by his neck disability. “Aggravated” means to cause any increase in severity that is beyond the normal progression of the disability. In addressing the above questions, the examiner should address and discuss the submitted February 2016 and February 2018 private medical opinions from Dr. O.S., which state that the Veteran’s headaches could reasonably be a result of his documented 1974 motor vehicle accident and/or due to cervical spondylosis/chronic neck pain. A complete rationale must be provided for all opinions expressed. If an opinion cannot be offered without resort to mere speculation, the examiner must indicate why this is the case and what additional evidence, if any, would allow for a more definitive opinion. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Robinson, 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.