Citation Nr: 21001448 Decision Date: 01/08/21 Archive Date: 01/08/21 DOCKET NO. 13-00 879 DATE: January 8, 2021 ORDER Entitlement to service connection for a headache disorder is granted. REMANDED Entitlement to service connection for temporomandibular joint (TMJ) syndrome, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. Entitlement to an initial rating in excess of 10 percent for degenerative changes of the lumbar spine for the period prior to January 2, 2019 is remanded. Entitlement to an initial rating in excess of 40 percent for degenerative changes of the lumbar spine for the period beginning January 2, 2019 is remanded. FINDING OF FACT Service treatment records note a complaint of headache associated with neck pain, the Veteran reported experiencing chronic headaches in 2010, and current medical evidence indicates the Veteran suffers from cervicogenic headaches. CONCLUSION OF LAW The criteria for service connection for a headache disorder are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from May 1987 to February 1995 and from March 1995 to August 2009. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). These matters were last before the Board in December 2017, when they were remanded for additional development. During the pendency of the last remand, entitlement to service connection for fibromyalgia was granted in a November 2020 rating decision. Accordingly, that issue has been resolved and is not presently on appeal before the Board. 1. Entitlement to service connection for headaches The Veteran contends that he suffers from chronic headaches that began in or are related to service. The Board concludes that the Veteran has a current disability that began during active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). During service, the Veteran was seen in August 2001 for neck and headache pain at the base of the skull. In May 2003, he had a headache associated with sinus symptoms. On VA examination in 2010, a few months after discharge, he reported headache once a week that lasts a full day and accompanied by nausea, but were not prostrating. VA examination reports from January 2019 and August 2019 indicate that the Veteran is diagnosed with cervicogenic headaches. The August 2019 cervical spine examination report noted that the Veteran’s pain started in his neck and radiated into the back of his head. The examiner opined that the Veteran’s cervicogenic headaches were a neurological abnormality related to his cervical spine disability. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current claimed disability arose in service. While the Board acknowledges that there are negative nexus opinions of record, the Veteran was shown to have a headache associated with neck pain during service, he was noted to have headaches shortly after discharge from service, and currently has a diagnosis of cervicogenic headaches. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for a headache disorder is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for TMJ syndrome, to include as secondary to service-connected posttraumatic stress disorder, is remanded. 2. Entitlement to an initial rating in excess of 10 percent for degenerative changes of the lumbar spine for the period prior to January 2, 2019 is remanded. 3. Entitlement to an initial rating in excess of 40 percent for degenerative changes of the lumbar spine for the period beginning January 2, 2019 is remanded. The evidence indicates there may be outstanding relevant VA treatment records. A VA treatment record from November 5, 2019 indicates that the Veteran was to return for an appointment on August 12, 2020. VA treatment records subsequent to July 13, 2020 have not been associated with the claims file. Additionally, VA record entries from January 25, 2010, February 9, 2010, February 16, 2010, July 29, 2010, July 11, 2011, July 10, 2012, February 13, 2020, April 20, 2020, and June 4, 2020 note that medication reconciliation records, consult reports, and non-VA care records from Serenity Holistic Wellness, Valley Chiropractic, and Baker Rehab Group had been scanned into VistA Imaging. It does not appear that the referenced records have been associated with the claims file. A remand to obtain the outstanding records is required. The December 2017 remand requested an opinion to determine whether the Veteran’s TMJ syndrome was related to service and/or his service connected PTSD. While an opinion was obtained in October 2020, it was not fully responsive to the remand request. Specifically, the clinician did not, as requested, address the October 2003 and December 2004 service treatment records reflecting clicking, popping and TMJ pain as well as combat stressors. Additionally, the clinician did not render the requested opinion regarding secondary service connection. Accordingly, another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, request any relevant records identified. In addition, obtain updated VA treatment records as well as the VistA Imaging records referenced in the January 25, 2010, February 9, 2010, February 16, 2010, July 29, 2010, July 11, 2011, July 10, 2012, February 13, 2020, April 20, 2020, and June 4, 2020 VA record entries. If any requested records are unavailable, the Veteran should be notified of such. 2. After records development is completed to the extent possible, obtain an addendum opinion regarding the Veteran's TMJ. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. After review of the claims file, the clinician should opine: (a.) Whether it is at least as likely as not (50 percent probability or greater) that TMJ had its onset during service or is otherwise related to service. In so opining, the clinician should address the October 2003 and December 2004 service treatment records reflecting clicking, popping and TMJ pain as well as combat stressors. (b.) Whether it is at least as likely as not (50 percent probability or greater) that TMJ was caused by the service-connected PTSD? (c.) If not caused by the service-connected PTSD, is it at least as likely as not that the Veteran's TMJ is worsened beyond natural progression (aggravated) by his service-connected PTSD? If the clinician finds that the Veteran's TMJ was aggravated by his service-connected PTSD, the clinician should attempt to quantify the level of aggravation beyond the baseline level of the TMJ. A complete rationale should be provided for all opinions and conclusions expressed. 3. If the claims remain denied, issue a supplemental statement of the case. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Anderson 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.