Citation Nr: 20034543 Decision Date: 05/18/20 Archive Date: 05/18/20 DOCKET NO. 16-17 984 DATE: May 18, 2020 REMANDED Entitlement to service connection for neck injury with arthritis is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1978 to July 1978 and from March 1981 to March 1985, and March 1985 to January 1987. The Board notes that the Veteran received an other than honorable discharge for the period of service from March 1985 to January 1987, which has been determined to preclude VA benefits for this period of service. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a February 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Board previously remanded this matter in October 2019 for further development. The Board’s October 2019 remand noted that the claims file contained VA treatment records that indicated the Veteran has chronic neck pain. The remand also noted the Veteran had asserted that his neck pain was caused by an accident during his active duty service wherein he was hit in the head and knocked unconscious. It further observed that there were no medical opinions of record which addressed a nexus between the Veteran’s neck injury with arthritis and his active duty service. The remand instructed that the Veteran should be afforded a VA neck (cervical spine) conditions examination with an examiner that had reviewed the claims file. The Board advised that an etiology opinion should be provided for any neck disorder diagnosed, and should address whether any diagnosis is related to the Veteran’s active military service, including his reported head trauma accident in 1982, but the opinion should be limited to the Veteran’s first two period of active military service (not the period from March 1985 to January 1987). A new examination was conducted in December 2019. The Board finds that the December 2019 VA examiner’s opinion lacks a sufficient rationale and did not address whether three post-service motor vehicle accidents the Veteran was involved in could have contribute in any way to the Veteran’s current neck disability. When the Veteran provided his medical history in the examination report, he reported the head trauma accident in 1982. He also stated that he has had rheumatology appointments since 1998 and that he was diagnosed with psoriatic arthritis in 2000. He further reported that he was in a car accident in December 2019 and was told he had a C4 fracture. The VA examiner opined that the Veteran’s neck condition was less likely than (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. They explained that the because the service treatment records referred to the injury sustained in the 1982 accident as a “head injury/laceration”, there was “NO indication of a cervical condition” at the time of said injury. The examiner also noted that the examination after the 1982 accident described the Veteran’s neck as being “supple”, which further showed the Veteran did not have a cervical condition at the time of the examination. This rationale ignored the Veteran’s lay statements that the medical staff treating him after his accident were so focused on treating his nose after the accident that they made no attempt to treat his neck. See Statement in Support of Claim, received by VA in September 2014. Moreover, although the examiner opined that the Veteran’s current cervical condition is more likely related to the recent cervical condition and the psoriatic arthritis, she then noted that a nexus had not been established. The examiner did not provide any information on what recent cervical condition she thinks the Veteran’s current cervical condition is related to and did not provide any rationale for that opinion. She also did not address any of the post-service motor vehicle accidents the Veteran was involved in (service treatment records indicate the Veteran was involved in motor vehicle accidents in 1999, 2010, and 2019) and whether they contributed to the Veteran’s current neck disability. See CAPRI, received by VA in January 2019. Therefore, the matter must be remanded to obtain a new medical opinion that fully addresses the etiology of the Veteran’s degenerative arthritis of the neck. The matters are REMANDED for the following action: 1. Make efforts to obtain all outstanding medical records in accordance with duties set forth in 38 C.F.R. § 3.159(c). 2. After obtaining any outstanding records, forward the Veteran’s claims file to a qualified medical professional to obtain an addendum opinion as to the nature and etiology of the Veteran’s neck disability. If, and only if, the clinician determines that an examination is necessary, one should be scheduled. After reviewing the record, the examiner must provide an opinion as to whether is at least as likely as not (50 percent or greater probability) that the Veteran’s neck disability is causally related to his active service (the first two periods, as noted above, but not the March 1985 to January 1987 period), to include his reported head trauma accident in 1982. If it is less likely that the Veteran’s current neck disability is related to his active service, the examiner should discuss why this is the case, with full consideration of the Veteran’s own reported history. The examiner must provide any and all opinions as to etiology in the form of a probability and must provide a complete rationale for any opinion expressed. The Board recognizes the practical difficulties of scheduling an examination in view of the COVID-19 epidemic, and requests flexibility and understanding in affording the Veteran an opportunity for an examination. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Fairlie, 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.