Citation Nr: 21000622 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 05-30 443 DATE: January 5, 2021 ORDER The claim of entitlement to service connection for alcohol dependence, to include as secondary to service-connected posttraumatic vascular headaches, is denied. The claim of entitlement to service connection for late effect traumatic brain injury (TBI), claimed as secondary to alcohol dependence, is denied. The claim of entitlement to service connection for anterior vermis syndrome, claimed as secondary to alcohol dependence, is denied. The claim of entitlement to service connection for alcoholic polyneuropathy is denied. FINDINGS OF FACT 1. Although no alcohol dependence or history of alcohol dependence was noted at service entry, it is established by clear and unmistakable evidence that the Veteran entered service with a pre-existing alcohol dependence. 2. It is established by clear and unmistakable evidence that the Veteran’s pre-existing alcohol dependence was not aggravated by service. 3. The competent, probative medical opinions to address the relationship, if any, between the Veteran’s service-connected posttraumatic vascular headaches and alcohol dependence weigh against the claim. 4. No neck disorder was shown in service or for many years thereafter; there is no credible evidence of continuity of symptoms of a neck disorder during and since service; the only competent, probative evidence or opinions addressing whether there exists a medical relationship between any current neck disorder and the Veteran’s service weighs against the claim. 6. As service connection for alcohol dependence has not been established, there is no legal basis to award secondary service connection for residuals of neck injury, late effect TBI, alcoholic polyneuropathy, or anterior vermis syndrome. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for alcohol dependence, to include as secondary to service-connected posttraumatic vascular headaches, are not met. 38 U.S.C. §§ 1110, 1111, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for late effect of TBI, claimed as secondary to alcohol dependence, are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for residuals of neck injury, claimed as secondary to alcohol dependence, are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for anterior vermis syndrome, claimed as secondary to alcohol dependence, are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for alcoholic polyneuropathy are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1972 to August 1973. This appeal to the Board of Veterans’ Appeals (Board) arose from a December 2004 rating decision in which the Department of Veterans Affairs (VA) Regional Office (RO), inter alia, declined to reopen a claim characterized as one for service connection for head trauma, as well as declined to reopen a claim for service connection for injury to neck vertebra. The Veteran disagreed with, and timely perfected an appeal as to, those denials. In August 2007, the Veteran testified during a Board video-conference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. In April 2011, the Board determined that the claim for service connection for residuals of a neck injury had not been previously adjudicated, and that, thus, this claim did not need to be reopened through the submission of new and material evidence. This issue was thus recharacterized as an original claim for service connection for residuals of a neck injury. This issue was remanded to the RO for adjudication on a de novo basis. Also, in April 2011, the Board determined that new and material evidence to reopen the claim for service connection for residuals of a head trauma, claimed as headaches, had been received. This claim was thus reopened and the claim for service connection, on the merits, was remanded to the agency of original jurisdiction (AOJ) for development and de novo adjudication. In July 2012, June 2013, May 2014, February 2016, and July 2017, the Board again remanded these claims to the AOJ. Regarding the characterization of the claims on appeal, in February 2016, the Board granted service connection for posttraumatic vascular headaches and recharacterized the appeal to separately include each identified medical diagnosis interrelated to the Veteran’s history of head trauma. For the reasons made clear below, the Board has expanded the appeal to include the claim for alcohol dependence as interrelated to the Veteran’s claims. The Board again remanded the claims on appeal in June 2019. The Board is now satisfied that all notification and development actions needed to fairly adjudicate each claim on appeal have been accomplished, and will now proceed to adjudicate the claims, at this juncture, Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in or aggravated by service. See 38 C.F.R. § 3.303(d). Generally, to establish service connection, there must be competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). See also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Certain chronic diseases shall be presumed to have been incurred in service if manifested to a compensable degree within a prescribed period post-service (one year for arthritis), even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. With chronic disease shown as such in service (or within the presumptive period under 38 C.F.R. § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributed to incurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumption period) is questioned. When the fact of chronicity is service is not adequately supported, then the showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.30(b). The United States Court of Appeals for the Federal Circuit has clarified that the provisions of 38 C.F.R. § 3.303(b) pertaining to the award of service connection of the basis of continuity of symptomatology (in lieu of a medical nexus opinion) apply to chronic diseases as defined in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection also may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires: (1) competent evidence (a medical diagnosis) of current disability; (2) evidence of a service-connected disability; and (3) competent evidence that the current disability was either (a) caused or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) (emphasis added); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Notably, under 38 U.S.C. § 1110, “no compensation shall be paid if the disability is a result of the Veteran’s own willful misconduct or abuse of alcohol or drugs.” However, if an alcohol or drug addiction was acquired as a result of a service-connected disability, then secondary service-connection may be available. See 38 U.S.C.A. § 105; 38 C.F.R. §§ 3.1(m), 3.301(d). See also Allen, 237 F.3d 1368 (noting that 38 U.S.C.A. § 1110 precludes compensation for primary alcohol and drug abuse disabilities but does not preclude compensation for an alcohol or drug abuse disability that is secondary to a service-connected disability). The determination as to whether each element of a claim is met is based on an analysis of all relevant evidence of record, and evaluation of its competency, credibility, and probative value. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Baldwin v. West, 13 Vet. App. 1, 8 (1999). Laypersons, such as the Veteran, are competent to report on matters observed or within his or her own personal knowledge, to include the occurrence of injury, and as to the nature, onset, and continuity of symptoms experienced or observed. See 38 C.F.R. § 3.159(a)(2); Charles v. Principi, 16 Vet. App. 370 (2002). Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board, however, retains the discretion to determine the credibility and probative value of all evidence of record, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). In adjudicating a claim for VA benefits, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Service treatment records (STRs) indicate that on September 11, 1972, the Veteran was referred to an ophthalmologist due to his report of blurred vision and double vision (diplopia) since November 1971, when he struck his head. He had not been rendered unconscious. He further reported hitting his head two weeks previous followed by 4 episodes of blurred and double vision. He also described headaches. The ophthalmologist offered an impression of probable partial paresis of cranial nerve VI secondary (2°) trauma. The report of a September 13, 1972, neurology consultation documents a similar history of the Veteran hitting the top of his head over a stairway before Thanksgiving 1971. He had been dazed temporarily, but had no loss of consciousness (L.O.C.). He reported that, since that time, he had experienced approximately 6 episodes of double vision which lasted from seconds to minutes. He had more frequent episodes of blurred vision for short periods of time which were occasionally, but not necessarily associated with, right fronto-temporal headache. These symptoms worsened with activity. The Veteran’s last episode of visual trouble occurred shortly after his hernia repair. The neurologist offered initial impressions of visual disturbance post-head trauma, post-traumatic headaches, doubt aneurysm and normal neurologic examination. A subsequently performed electroencephalogram (EEG) was interpreted as within normal limits for the Veteran’s age. The report of an October 1972 neurology consultation reflects the Veteran’s report that his diplopia had resolved, but that he had experienced orthostatic dizziness and almost daily, throbbing frontal headaches (HA). It was noted that an x-ray showed some calcification (probable dural). The examiner offered an impression of post-traumatic vascular headache and prescribed Tegretol. Thereafter, the Veteran reported some continued double vision and he was placed on limited duty due to headaches. A December 1972 neurology consultation reported the Veteran to have a history of dizziness and VI cranial nerve weakness possibly representing a small brain stem injury. The examiner recommended the Veteran be discharged with a diagnosis of post-concussion headaches which existed prior to service (EPTE). A January 1973 Report of Medical Board from the Naval Hospital at Camp Lejeune, North Carolina, reflects that the Veteran reported having suffered a head injury prior to his entry into service. Specifically, this record notes that the Veteran struck the top of his head on the ceiling over a stairway in late November 1971. He was temporarily dazed, but did not lose consciousness. Since that time, the Veteran had experienced short, frequent episodes of blurred vision, at least six episodes of diplopia (double vision) lasting from seconds to minutes, and frequent throbbing, right frontotemporal headaches. The Veteran was placed on various medications, with varying degrees of efficacy, but was able to perform no more than light duty. The Medical Board report recommended a six-month period of limited duty. An April 1973 neurology note reflects that the Veteran’s headaches were adequately controlled with Propanol and Valium. It was noted that the Veteran required a medical discharge for “EPTE, aggravated.” The Veteran was reevaluated in July 1973, and the resulting Medical Board report describes the treatment the Veteran had received in the intervening six months. This record reflects that, “[a]fter an adequate period of evaluation and treatment, a conference of the staff neurologist and psychiatrists reviewed the findings and agreed that the patient had a history of post-traumatic vascular headaches which existed prior to enlistment and were aggravated by a period of active duty. . . .” It was also noted that the headaches had not improved sufficiently to return the Veteran to full duty status. The Medical Board opined that the Veteran was unfit for further military service, and it was recommended that his case be referred to the Physical Evaluation Board for final disposition. A July 1973 “Physical Evaluation Board - Proceedings and Findings” lists a diagnosis of post-traumatic, vascular headaches, existed prior to entry, not aggravated, and not ratable. Post-service medical evidence includes a December 1974 hospitalization record from the Hines VA hospital indicating that the Veteran reported having intermittent supra-orbital headaches since being beaten up by MPs in September 1972. He described being worked up extensively in September 1972 and being placed on Valium and Talwin. He had a recent history of tinnitus after taking aspirin. A history obtained by the Veteran’s father indicated that the Veteran was addicted to marijuana and heroin, which he began using in service. A general physical and radiological examination during this hospitalization was within normal limits. An EEG showed excessive artifacts with possible left temporal slowing. The Veteran was given discharge diagnoses of tension headache and drug addiction. In June 1979, the Veteran was admitted to the Hines VAH as a result of gross hematuria secondary to left flank trauma which he sustained in a fist fight. Later that month, the Veteran filed a VA Form 21-526 (Veteran’s Application for Compensation or Pension) “Head Injury - Migraine Headaches” treated in service “Aug Sept 1972.” On his initial VA examination in March 1980, the Veteran alleged having incurred migraine headaches and a bruised kidney during active service. He reported treatment for multiple injuries and migraine headaches at Camp Lejeune from June 1972 to March 1973 as well as migraine headaches and a bruised kidney at the Hines VAH in February 1974. On interview, that the Veteran stated that, while stationed at Camp Lejeune in July 1972, he was hit over the head with blackjacks by division MPs. He had experienced headaches, which occurred when under tension, since this injury. He took Tylenol to treat his headaches which, while not relieving his headaches, did relieve some of the pressure. He reported that he began drinking at 19 years of age and drank on average one case of beer and one quart of whiskey per week. He also used marijuana and downers. The examiner offered a diagnosis of psychophysiological musculoskeletal disorder manifested by tension headaches and commented that there were insufficient findings and symptoms to support a diagnosis of posttraumatic vascular headaches, which was the in-service diagnosis. The examiner also certified that the Veteran did not experience migraine headaches. A June 1989 VA clinic record includes the Veteran’s report of incurring a concussion and right kidney injury as a result of being beaten by MPs in service. In February 1991, the Veteran was hospitalized at the Iowa City VA Medical Center (VAMC), in part, for substance abuse. He described a 17-year history of alcohol abuse with black outs and withdrawal seizures. The examining clinician indicated that the Veteran’s excuse for drinking “is that he often starts to drink when he sees something that reminds him of one of his wives.” The Veteran also reported a history of drug use which included LSD, cocaine and intravenous (IV) drugs. At this time, he reported left arm pain and tingling. A magnetic resonance imaging (MRI) scan showed disc herniation at the C5-6 and C6-7 levels. Another Iowa City VAMC hospitalization, in March 1991, included the Veteran’s report of the onset of numbness and tingling sensation of both hands and the left arm in January 1991. At this time, he reported first drinking at the age of 13 with regular use at age 16 or 17. He currently drank one-fifth of schnapps per day and described being in many fights in bars stating “that is how I lost [my] teeth.” In April 1991, the Veteran underwent anterior cervical fusion with diskectomy at C6-C7 at the Iowa VAMC. At this time, he reported a “several month history” of neck pain with pain and paresthesias radiating to his left arm. He denied a previous trauma history. His discharge diagnoses included alcohol dependence, history of polysubstance abuse, history of cannabis use and antisocial personality traits. The Veteran’s medical records subsequently reflect continuing treatment for headaches, substance abuse and neck pain. He underwent a second neck surgery in February 1992. In April 1997, he was treated for alcoholic liver disease with secondary portal hypertension and dyspnea. At this time, the Veteran described alcohol abuse consisting of a six pack with a pint of gin daily. His mother asserted that, to be more accurate, the Veteran drank double or triple this amount. The Veteran reported that his neck pain was secondary to neck surgery in 1991 and 1992. A May 2004 VA psychiatric outpatient clinic consultation report documents the Veteran’s report of recurrent thoughts about being beaten by MPs in service, which required a hospitalization “for many weeks.” Notably, he reported a history of antisocial behavior stating “I lied all my life. I have done stupid things all my life.” An August 2004 VA general medical examination report reflects no complaint of blurred or double vision, but notes that cranial nerves II through XII were grossly intact. An August 2004 VA mental disorders examination, which was conducted without review of the claims file, provided diagnoses of major depression and alcohol dependence. The Veteran described his major medical difficulty as “chronic pain due to service-connected injuries to his neck and head.” The examiner stated that, “[i]n my opinion, the [Veteran’s] alcohol dependence is secondary and is a result of and an attempt to self-medicate his more primary diagnosis of pain and depression.” A May 2005 VA treatment record reflects the Veteran’s report that his first drink and use of cannabis occurred at the age of 12, while the record of another visit that same month reflects a history of drinking which started at the age of 16. He described increased alcohol use during service. It was also noted that the Veteran experimented with many illegal substances, to include mescaline, acid and IV heroin, in the 1960s-70s. An October 2006 VA treatment record includes the Veteran’s report of being hit on the head with a hammer during a robbery in November 2005. At a February 2007 eye consultation, the Veteran reported near and distance vision problems, but did not report blurred or double vision problems. No abnormality of cranial nerve VI was noted. In March 2007, he sustained a cervical fracture. In May 2009, the Veteran reported that he started drinking at age 14 and only had three periods of sobriety since, including two months in boot camp. He reported that he “just started drinking again for no reason.” At that time, he demonstrated bilateral lower extremity weakness (BLE) with ataxic gait and spasticity in the lower extremities. A neurology consultation indicated that examination findings were consistent with possible chronic sensorimotor distal polyneuropathy due to chronic alcohol abuse. Following diagnostic studies, the VA neurologist diagnosed the Veteran with anterior vermis syndrome secondary to alcohol, alcoholic polyneuropathy, and old cervical contusion with front and back fusions. At this time, the Veteran reported being struck in the head with a hammer during a home robbery. The claims file reflects that multiple VA opinions have been obtained as part of the development on appeal. In June 2011, the Veteran underwent VA Compensation and Pension (C&P) examination with benefit of review of the claims file. The examination report references the STR circumstances as well as the Veteran’s report in VA clinical records regarding the onset of drinking prior to service. The Veteran additionally reported that, after his neck surgery in 1991, he reinjured his neck falling off a ladder and additionally incurred a cervical fracture in 2007. The examiner also referenced the Veteran’s reported histories of head traumas. The VA examiner provided diagnoses of frontotemporal headaches, alcoholic ataxia, temporary left VI nerve paresis causing blurring of vision for short periods of time and multiple episodes of diplopia lasting from seconds to minutes, and alcoholic neuropathy. The examiner opined that the Veteran had head and neck trauma which pre-existed service with the same symptoms reported during service. The examiner then commented that the Veteran had multiple far more severe bouts of head and neck trauma via his continuous drinking behavior with multiple altercations resulting in multiple neck surgeries 20 years post-service. The examiner indicated that the Veteran’s left VI nerve paresis was temporary in nature, had resolved prior to service, and was not presently symptomatic. The examiner explained that the major problem appears to be the Veteran’s chronic longstanding alcoholism which seems to have caused him to get into multiple altercations which have resulted in head and neck trauma with memory loss; decreased concentration; inappropriate behavior; poor social interactions; difficulty following instructions; pain. Additionally, pain, easy fatigue, and weakness due to his multiple neck injuries. The examiner opined that the Veteran’s diagnosis of status post cervical fracture was not related to events in service with rationale that he sustained this injury in a fall in 2007. In a statement received in March 2012, the Veteran denied having posttraumatic headaches prior to service, and asserted that his headaches began after being beaten by MPs at Camp Lejeune. He described being hospitalized for almost three weeks after the beating, and placed on light duty for many months following his hospitalization. He also asserted that his chronic headaches contributed to his alcoholism and drug use, and that his substance abuse contributed to his long string of altercations with the exception of a robbery where he was beaten with a hammer. A January 2014 VA C&P examination report, which notes review of the claims file, documents diagnoses of chronic posttraumatic headaches, status post cervical fracture, alcoholic polyneuropathy, late effect of TBI, anterior vermis syndrome with ataxia secondary to alcohol, probable cervical radiculopathy and temporary left abducens nerve injury. In pertinent part, the examiner opined that it was less likely than not that the Veteran’s diagnoses of chronic posttraumatic headaches, status post cervical fracture, alcoholic polyneuropathy, late effect of TBI, anterior vermis syndrome with ataxia secondary to alcohol, probable cervical radiculopathy and temporary left abducens nerve injury were due to or the result of service. As rationale, the examiner indicated that the Veteran’s first report of head trauma was prior to service, that his left abducens injury was temporary in nature, that his cervical fracture occurred after service, that his various head traumas occurred prior to or after service, that his anterior vermis syndrome and alcoholic polyneuropathy was alcohol-related with use which began prior to service and that his cervical traumas were the result of numerous alcohol-related altercations. In a March 2014 addendum opinion, the January 2014 C&P examiner opined that the Veteran’s chronic posttraumatic headaches clearly existed prior to enlistment and was not aggravated by events in service. The examiner indicated that the Veteran’s only trauma in service was “sustained in an altercation, which is why he was not service connected for it.” The examiner attributed the Veteran’s cervical fracture to a falling injury in 2007. The examiner also attributed the Veteran’s alcoholic polyneuropathy, late of effect of TBI and anterior vermis syndrome with ataxia to alcohol abuse which began prior to service, wherein he was having numerous blackouts, and continued drinking since service. Finally, the examiner found that the Veteran had an apparent temporary left abducens nerve paresis which was present prior to diagnosis in September 1972, as represented by his reports of several episodes of blurred vision or double vision since November 1971. It was noted that alcohol could cause pseudoabducen’s palsy as part of intoxication, that repeat eye consults did not show this finding, and that skull films were negative. In a second addendum opinion dated in May 2015, the January 2014 C&P examiner opined that the Veteran’s chronic posttraumatic headaches, late effects of TBI, and temporary left abducens nerve injury clearly and unmistakably existed prior to service and were clearly and unmistakably not aggravated during military service. The rationale from the prior opinions remained the same. The AOJ obtained another VA C&P examiner opinion, from a different C&P examiner, in July 2015. This report reflects an extensive review of the evidentiary history including the opinions from the January 2014 VA C&P examiner. Following review of the claims file, the July 2015 VA C&P examiner opined, in pertinent part, that the Veteran’s diagnosed disabilities of status post cervical fracture, late effect traumatic brain injury, alcoholic polyneuropathy, anterior vermis syndrome with ataxia secondary to alcohol, and probable cervical radiculopathy, were found not to have clearly and unmistakably existed prior to service, are less likely than not (less than 50 percent probability) related to the Veteran’s military service. He explained that review of STRs show that the Veteran entered military service without history or clinical finding of disability as documented in his May 1972 physical enlistment. He also noted that review of the Veteran’s active duty STRS do not contain evidence of the Veteran being evaluated for complaints or injuries of the cervical spine, thoracolumbar spine, or fitness for duty related to alcohol or marijuana use. He concluded that the above-identified disabilities developed after the Veteran’s military service as a consequence of alcoholism and are not associated with the Veteran’s post traumatic, vascular headaches. In October 2017, a VA physician opined that the Veteran’s alcoholic polyneuropathy is less likely than not incurred in or caused by the veteran’s alcohol dependence during service. He explained his alcoholic polyneuropathy is also less likely than not a primary or secondary disorder caused and/or aggravated beyond normal progress of the disorder by his service-connected posttraumatic vascular headaches. The examiner essentially relied on the rationale provided in the July 2015 VA opinion. In a March 2020 VA addendum opinion, the 2011 VA examiner opined that it is less likely than not that the Veteran’s alcohol dependence is a primary disorder, or a secondary disorder caused or aggravated by his service connected post traumatic vascular headaches. She explained that the Veteran’s alcohol dependence and vascular headaches both preceded his time in service. She noted he first began drinking alcohol and using illicit substances at age 12 and was a regular user of alcohol and illicit substances by age 16 to 17 and that his headaches had also existed prior to enlistment, and per December 1972 neurology examination, had been secondary to a concussion 2 years previously, e.g. prior to his entry into active service in April 1972. Although the Veteran has alleged that his chronic headache disorder has contributed to his alcohol use, in the March 2012 statement, the physician concluded it is somewhat more likely that his alcohol use contributed to his headache disorder rather than the other way round, especially given his history of altercations and the neurological diagnosis of post traumatic headaches as a result of his altercations. She noted that although in July 1973, he appeared before a medical board where it was noted that after an adequate period of evaluation and treatment, a conference of the staff neurologist and psychiatrists reviewed the findings and agreed that the patient had a history of post-traumatic vascular headaches which existed prior to enlistment and were aggravated by a period of active duty and that the headaches had not improved sufficiently following a six-month period of limited duty to return the patient to full duty status, it is noteworthy that this medical board was unaware of the Veteran’s history of polysubstance abuse with onset at age 12. Although the Veteran later stated that the head trauma occurred while being beaten up by MPs in the service, she stated there is no evidence supporting that statement, and the Veteran's long standing polysubstance abuse beginning at age 12, his lack of candor in admitting to his treating VA physician that "I lied all my life" (see VA clinic record dated May 2004); the report of the Veteran's father regarding the onset of marijuana and heroin abuse in service (see VA hospitalization record dated in December 1974), and the report of the Veteran's mother that the Veteran has underreported the extent of his alcohol use by a factor of 2 or 3 casts doubt on his veracity. 1. Alcohol dependence Here, the Veteran does not dispute his long-term alcohol use but alleges that his service-connected chronic headache disorder contributes to his alcohol use. In addition to the basic legal authority governing service connection cited above, pertinent to this claim, it is noted that every person employed in the active military, naval, or air service shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111. To rebut the presumption of soundness in 38 U.S.C. § 1111, VA must show, by clear and unmistakable evidence, (1) that the disease or injury existed prior to service, and (2) that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). The claimant is not required to show that the disease or injury increased in severity during service before VA’s duty under the second prong of this rebuttal standard attaches. Id. See also Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). By “clear and unmistakable evidence” is meant that which cannot be misunderstood or misinterpreted; it is that which is undebatable. Vanerson v. West, 12 Vet. App. 254 (1999). In determining whether there is clear and unmistakable evidence to rebut the presumption of soundness, all evidence of record must be considered, including post-service medical opinions. Harris v. West, 203 F.3d 1347 (Fed. Cir. 2000); Adams v. West, 13 Vet. App. 453 (2000). The term “noted” denotes only such disorders that are recorded in examination reports. The existence of disorders prior to the active military service reported by the veteran as medical history do not constitute a notation of such disorders, but it will be considered together with all of the other evidence in question as to the commencement of the disease or disorder. 38 C.F.R. § 3.304 (b)(1). Determinations of whether a disorder pre-existed the active military service should be based on a thorough analysis of the evidentiary showing and careful correlation of all medical facts, with due regard to manifestations, clinical course and character of the particular injury or disease or residuals thereof. Id. An injury or disease that has been determined to be pre-existing will be presumed to have been aggravated by service where there is an increase in the severity of the disability during service. The burden to show no aggravation of a pre-existing disease or disorder during service lies with the government. Cotant v. Principi, 17 Vet. App. 117, 131 (2003). However, considering the pertinent evidence in light of the applicable legal authority, the Board finds that service connection for alcohol dependence is not warranted. The record contains competent evidence of alcohol dependence. Also, as alcohol dependence was not specifically noted on the Veteran’s May 1972 service enlistment examination report, the Veteran is entitled to a presumption of soundness with respect to alcohol dependence. In this case, however, the Board also finds that there is sufficient evidence of record, to include but not limited to the Veteran’s own statements, to rebut the presumption. As noted, the Veteran has acknowledged that his alcohol dependence pre-existed service, and a May 2005 VA treatment record reflects the Veteran’s report that his first drink and use of cannabis occurred at the age of 12 while another visit that same month reflected a history of drinking which started at the age of 16. The Veteran also indicated in 2007 that he began drinking at 14 years old. Moreover, based on review of the claims file, to include the medical treatment records, the Veteran’s statements, the VA examiners and physicians opined that the Veteran’s alcohol dependence clearly and unmistakably existed prior to service. On the question of aggravation of the pre-existing alcohol dependence, the Veteran seems to argue that his posttraumatic vascular headaches during service worsened his alcohol dependence. However, as noted by the multiple VA examiners and physicians, the Veteran’s pre-existing alcohol dependence was not caused and or aggravated his service-connected posttraumatic vascular headaches. Notably, in this regard, the April 2011 examination report references the STRs circumstances as well as the Veteran’s report in VA clinic records regarding the onset of drinking prior to service, the 2014 VA examination report noted that his alcohol use began prior to service, in the March and May 2015 addendum opinions, the examiner indicated that the Veteran’s alcohol abuse began prior to service, wherein he was having numerous blackouts, and continued drinking since service. Further, the March 2020 VA opinion also concluded it is less likely than not that the Veteran’s alcohol dependence is a primary disorder, or a secondary disorder caused by or aggravated by his service connected post traumatic vascular headaches. She explained that the Veteran’s alcohol dependence and vascular headaches both preceded his time in service, as he first began drinking alcohol and using illicit substances at age 12 and was a regular user of alcohol and illicit substances by age 16 to 17 and that his headaches had also existed prior to enlistment, and per December 1972 neurology examination. She further explained that it is somewhat more likely that his alcohol use contributed to his headache disorder rather than the other way around, especially given his history of altercations and the neurological diagnosis of post traumatic headaches as a result of his altercations. Significantly, there is no contrary medical evidence or opinion on this point. The Board finds the VA medical opinions to be of significant probative value. The examiners and physicians all based their conclusions on examination of the Veteran and/or consideration of his documented history and assertions, and such conclusions were supported by stated rationale. Given this, and the fact that the conclusions are consistent with the evidence of record, the Board accepts these conclusions as probative evidence on the questions of pre-existence and in-service aggravation upon which this claim turns. See, e.g, Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). As for the Veteran’s own assertions as to in-service aggravation, the Board points out that matters pertaining to medical etiology of a disability—to include underlying questions of pre-existence and aggravation of such disability typically are matters within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). Although lay persons are competent to provide opinions on some simple medical issues (see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011)), the specific matters under consideration are complex medical matters that fall outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d at 1377 n. 4 (holding that lay persons are not competent to diagnose cancer). As neither the Veteran nor his representative are shown to have the training and expertise to competently opine as to the etiology of current alcohol dependence specifically, in-service aggravation of such a pre-existing disability the lay assertions in this regard are not competent, and, hence, not probative. In addition, the Veteran’s report that his headaches caused his alcohol dependence is inconsistent with the records, as the evidence indicates that he began drinking alcohol since 12 years of age consistent with the VA examiners’ and physicians’ conclusions. With regard to service connection on a secondary basis, the Board finds the VA opinions with respect to the relationship between the Veteran’s alcohol dependence and his service-connected posttraumatic vascular headaches to be fully informed, fully articulated, and well-reasoned. The examiners and VA physicians clearly described the history of the Veteran’s alcohol dependence starting at age 12, as stated by the Veteran, and that his alcohol dependence precipitated his headaches symptoms and clearly explained that the alcohol dependence symptoms were not attributable to the Veteran’s service-connected posttraumatic vascular headaches. The March 2020 VA opinion also indicated that the Veteran’s alcohol dependence caused or aggravated his posttraumatic vascular headaches, rather than the other way around. Significantly, there is no contrary medical evidence or opinion on this point. As such, the Board accepts the VA examiners’ and physicians’ conclusions as probative evidence on the matters upon which this claim turns. See, e.g. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). As the preponderance of the evidence is against the claim, the benefit-of the doubt doctrine is not for application, and service connection for alcohol dependence, to include as secondary to service-connected posttraumatic vascular headaches, must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-57. 2. Residuals of neck injury Considering the evidence of record in light of the above, the Board finds that service connection for residuals of neck injury is not warranted under any potentially applicable theory of entitlement. Despite the Veteran’s report that he injured his neck during service, the STRS do not reflect that the Veteran incurred any neck injury during service and the Veteran himself, indicated that his neck injury occurred after service. In this regard, as noted above, in April 1991, the Veteran underwent anterior cervical fusion with diskectomy at C6-C7 at the Iowa VAMC when he reported a “several month history” of neck pain with pain and paresthesias radiating to his left arm and he denied a previous trauma history. He underwent a second neck surgery in February 1992. In April 1997, the Veteran described alcohol abuse consisting of a six pack with a pint of gin daily and he reported that his neck pain was secondary to neck surgery in 1991 and 1992. The Veteran also fractured his neck in 2007. The VA opinions also explained that the Veteran’s neck injuries were caused by his falls and altercations as a result of his alcohol dependence, which is not related to service, as discussed above. Significantly, moreover, there is no competent or credible evidence or opinion even suggesting a relationship between a neck disability and any injury, disease or event in service. The Veteran’s service treatment records are negative for any findings or diagnosis of a neck disability; hence, the disability was not shown in service. Furthermore, there is no documented diagnosis until 1991, over 19 years after service discharge, and, which is also well beyond the period for establishing service connection for a neck disability, to include on a presumptive basis. See 38 C.F.R. §§ 3.307, 3.309. The Board also points out that the passage of many years between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Finally, as for the Veteran’s own assertions purporting to relate his residuals of neck injury to service, the Board acknowledge that as a layperson, he is certainly competent to attest to matters within his own personal knowledge, such as matters observed or experienced (see, e.g., Washington v. Nicholson, 19 Vet. App. 362, 367- (2005)), and may opine as etiology of some simple disabilities, such as those observable or otherwise perceived through the senses (see Kahana, supra). However, the matter of diagnosis and etiology of the medically complex disability here at issue is based on internal processes not observable to the human eye or otherwise perceived through the senses; hence, questions of diagnosis and etiology of such a disability are only within the province of individuals with special knowledge, training, and experience. See Jandreau, 492 F.3d at 1377, n. 4 (a layperson may be competent to attest to a broken leg, but not to diagnose cancer). As the Veteran is simply not shown to have such special knowledge, training, and experience, his assertions as the etiology of his residuals of a neck injury are not competent, and hence, not probative. In addition, the Veteran’s, himself, indicated that his neck symptoms did not begin until 1991, as discussed above. Accordingly, in this case, the Veteran cannot establish his claim on the basis of such lay assertions, alone. For all the forgoing reasons, the matter of direct service connection for residual of neck injury must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-57. 3. Secondary Service Connection With respect to any theory that alcoholic polyneuropathy, late effect of TBI and anterior vermis syndrome with ataxia to alcohol abuse, or residuals of neck injury, is/are secondary to alcohol dependence, the competent probative evidence of record indicates that the Veteran’s alcohol dependence is not related to service and is not a primary or secondary disorder caused by or aggravated by his service-connected posttraumatic vascular headaches, as discussed above. As such, there is no legal basis for an award of service connection for alcoholic polyneuropathy, late of effect of TBI and anterior vermis syndrome with ataxia to alcohol abuse, and residuals of neck injury, as these disabilities have been attributed to his non-service-connected alcohol dependence. As detailed above, the VA examiners and physicians attributed the Veteran’s alcoholic polyneuropathy, late of effect of TBI and anterior vermis syndrome with ataxia, and neck injuries to alcohol abuse which, again, began prior to service, wherein he was having numerous blackouts, and continued drinking since service. The 2016 examiner also indicated that the Veteran’s first report of head trauma was prior to service, that his cervical fracture occurred after service, that his various head traumas occurred prior to or after service, that his anterior vermis syndrome and alcoholic polyneuropathy was alcohol-related which began prior to service and that his cervical traumas were the result of numerous alcohol-related altercations. The VA opinions collectively provided negative opinions with sufficient rationale. Thus, there is no legal basis for awarding secondary service connection for these disabilities, as the Veteran has not been awarded service connection for an alcohol dependence disorder. Where, as here, service connection for a primary disability has not been awarded, the Veteran cannot establish entitlement to service connection, pursuant to 38 C.F.R. § 3.310), for a secondary condition. Thus, any assertion as to secondary service connection for alcoholic polyneuropathy or linking late effect of TBI and anterior vermis syndrome with ataxia to alcohol abuse, and/or claim that residuals of neck injury are secondary to alcohol dependence, each is without legal merit. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). JACQUELINE E. MONROE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sarah Campbell, 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.