Citation Nr: 21063891 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 17-37 213 DATE: October 18, 2021 ORDER Service connection for the Veteran's cervical spine disability, as currently diagnosed, is granted. Service connection for right upper extremity cervical radiculopathy is granted. Service connection for left upper extremity cervical radiculopathy is granted. Service connection for headaches is granted. REMANDED Entitlement to service connection for a low back disability is remanded. FINDINGS OF FACT 1. The Veteran's current cervical spine disability was incurred in service. 2. The Veteran has right upper extremity cervical radiculopathy secondary to his service-connected cervical spine disability. 3. The Veteran has left upper extremity cervical radiculopathy secondary to his service-connected cervical spine disability. 4. The Veteran's headaches are secondary to his service-connected cervical spine disability, with bilateral cervical radiculopathy. CONCLUSIONS OF LAW 1. The criteria for service connection for the Veteran's cervical spine disability, as currently diagnosed, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for right upper extremity cervical radiculopathy as secondary to the service-connected cervical spine disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for left upper extremity cervical radiculopathy as secondary to the service-connected cervical spine disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for service connection for headaches as secondary to the service-connected cervical spine disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1988 to March 1989, from November 1990 to June 1991, and from October 1991 to February 1992. These matters come before the Board of Veterans' Appeals (Board) from a November 2015 rating decision. The Board remanded these matters in June 2020. 1. Service connection for a cervical spine disability is granted. The Veteran seeks service connection for a neck disability, described as a neck injury. 05/29/2015, VA 21-526EZ, Fully Developed Claim. The Veteran has indicated that he injured his neck during a motor vehicle accident while deployed in the Persian Gulf. 09/22/2016 Hearing Testimony. Military personnel records confirm that the Veteran served in Southwest Asia from January 1991 to May 1991, in support of Operation Desert Shield/Desert Storm. His military occupational specialty (MOS) was heavy wheel vehicle mechanic. 03/29/2017, Certificate of Release or Discharge from Active Duty A May 2016 treatment record reflects the Veteran's report that during active duty in 1991 he was traveling through the desert and heard his neck snap. He reported having neck issues since. He further reported going to the field hospital after the event. The examiner diagnosed cervicalgia. The examiner stated that the Veteran's symptoms started after hitting his head on the roof of the jeep while active in the military. 06/22/2017 Medical Treatment Record-Non-Government Facility at 24-27. A November 2016 occupational therapy record reflects chronic neck pain. The Veteran reported that he has had pain in the upper trapezius and right infraspinatus musculature, with distal radiation, since an event in 1991 while in Saudi Arabia. He reported that he had been driving a recovery wrecker when he had an abrupt forward tilt of the terrain, his seat compressed and he was thrown up into the ceiling, hitting it with his head, then falling to the left with abrupt flexion of the neck. He recalled being treated with Motrin and was issued a neck collar he did not wear. Since that time his pain has persisted. A November 2016 cervical spine x-ray reflects no fracture or subluxation with the vertebral body heights maintained; intervertebral disc height loss at C5-6 and C6-7 with anterior osteophytes; alignment was normal; bony mineralization was normal; prevertebral soft tissue was normal; with no bony neural foraminal narrowing. 03/14/2017 CAPRI at 2-3. An April 2017 VA treatment record reflects the Veteran's report of right arm and cervical pain. He reported that this first started in the early 1990s during Desert Storm. He was deployed when the vehicle he was driving in hit a berm. He reported being thrust up and hitting the ceiling of the vehicle but with his neck at a peculiar angle. He was seen by the field doctors, treated with a neck brace and Motrin but he has continued to have neck pain. He has also had low back pain from a variety of injuries during deployment and has also had a slip and fall as a postman and has undergone two hip replacements. The impression was cervical and lumbar pain with cervical radiculopathy and question intermittent lumbar radiculopathy. 04/28/2017 CAPRI at 1. *** A September 2020 VA examination shows diagnoses of degenerative arthritis of the cervical spine and spinal stenosis, with bilateral cervical radiculopathy. The examiner opined that these diagnoses are less likely than not related to service. The examiner acknowledged the Veteran's self-report of a neck injury but concluded that "given that I do not have a nexus or chronicity in service or within one year of discharge it would be less likely than not incurred in or caused by the claimed in-service injury, event, or illness." This opinion is not supported by a medical rationale. Rather, it simply relies on the absence of documentary evidence to rule out a nexus between service and the current disability. Similarly, the opinion does not show adequate consideration of the Veteran's competently reported in-service neck injury and the extent to which such an injury may have contributed to the Veteran's neck disability. Therefore, an adequate opinion is not of record. After careful consideration of the evidence of record, the Board finds that service connection is warranted for the Veteran's cervical spine disability. As detailed above, the Veteran has a diagnosis of degenerative arthritis and spinal stenosis. In different occasions, including treatment visits, he has provided details regarding a significant neck injury in service and asserts that he was seen by the field doctors and treated with a neck brace and Motrin. Service treatment records do not include record of such treatment. The Board, however, finds that the Veteran's reports are credible and sufficient to establish that he experienced a significant neck injury in service. Similarly, the Board finds credible the Veteran's report of continuous symptoms since service. The continuity of symptoms for this chronic disease (arthritis) between the in-service injury and the current arthritis symptoms is sufficient to establish that the current neck disability was incurred in service. 38 C.F.R. §§ 3.303(b), 3.309(a). For these reasons, service connection for the Veteran's cervical spine disability is granted. 2. Service connection for right upper extremity cervical radiculopathy is granted. 3. Service connection for left upper extremity cervical radiculopathy is granted. The Veteran seeks service connection for bilateral upper extremity disability, described as numbness in the right arm and hand. 05/29/2015, VA 21-526EZ, Fully Developed Claim. He asserts that this disability is secondary to his neck injury. 05/29/2015, VA 21-526EZ, Fully Developed Claim. A September 2020 VA examination confirms that the Veteran has bilateral arm radiculopathy secondary to his now service-connected cervical spine degenerative joint disease. Secondary service connection for the bilateral cervical radiculopathy is therefore warranted. 38 C.F.R. § 3.310(a). 4. Service connection for headaches is granted. The Veteran seeks service connection for headaches. He asserts that this disability is secondary to his neck injury. 05/29/2015, VA 21-526EZ, Fully Developed Claim. A September 2020 VA examination shows a diagnosis of tension headaches secondary to the now service-connected cervical degenerative joint disease/stenosis with bilateral arm cervical radiculopathy. Secondary service connection for headaches is therefore warranted. 38 C.F.R. § 3.310(a). REASONS FOR REMAND 1. Service connection for a low back disability is remanded. The Veteran seeks service connection for a low back disability, described as lower back stiffness. 05/29/2015, VA 21-526EZ, Fully Developed Claim. In October 2013, the Veteran complained of lower right back pain. 05/29/2015 Medical Treatment Record-Non-Government Facility at 2. In September 2014, he sought follow-up treatment for lower back pain and an MRI of the lumbar spine was ordered. Id. at 4. An October 2014 MRI reflects moderate-central stenosis at L4-5 due to facet arthropathy and diffuse disk bulge; and, left paracentral protrusion at L5-S1 with slight indentation of the thecal sac and abutting descending left S1 nerve roots as they course through the lateral recess with no foraminal encroachment at any level. Id. at 8-9. In October 2016, the Veteran sought treatment for hip and back pain. He reported that while in the military he rode frequently in tractor trailer vehicles that had no suspension and was jostled around frequently. One day his legs went numb after a ride. He worked as a mechanic and was frequently going up and down and crawling in small spaces as part of his job. He was interested to know whether the examiner thought that his need for early hip replacements and degenerative disease as well as his lumbar disease may be related to his time in the military. The examiner diagnosed lumbar radiculopathy and the examiner stated that he could not confirm with certainty that his symptoms are due to his service. The examiner stated that certainly the details of him having sudden onset numbness is concerning for correlation. His current MRI was somewhat nonspecific apart from some mild degenerative joint disease, hemangiomas and mild stenosis. He has also been a post office worker for years and it is possible his back pain is related to his work there as well. 06/22/2017 Medical Treatment Record-Non-Government Facility at 14-15. A September 2020 VA examination shows a diagnosis of degenerative arthritis of the lumbar spine, with bilateral lumbar radiculopathy. Regarding onset, the examination report indicates that the Veteran injured his back in 1995 because of a fall while working at the post office and has had ongoing back pain since then. The examiner opined that the Veteran's lumbar spine disability is less likely than not related to service. The examiner acknowledged the Veteran's report of back symptoms in service but concluded that "given that I do not have a nexus or chronicity in service or within one year of discharge it would be less likely than not incurred in or caused by the claimed in-service injury, event, or illness." This opinion is not supported by a medical rationale. Rather, it simply relies on the absence of documentary evidence to rule out a nexus between service and the current disability. Similarly, the opinion does not show adequate consideration of the Veteran's report of back symptoms in service and the extent to which the Veteran's strenuous service as a heavy wheel vehicle mechanic may have contributed to the development of his lumbar spine disability. Therefore, an adequate opinion is not of record. A new opinion is therefore necessary. This matter is REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's lumbar spine disability is at least as likely as not ((probability of approximately 50 percent) related to service. The examiner is to address the Veteran's assertion that the strenuous nature of his service contributed to the development of his lumbar spine disability. Regarding his military duties, the Veteran has reported that, while in the military, he rode frequently in tractor trailer vehicles that had no suspension and was jostled around frequently, that one day his legs went numb after a ride, and that he worked as a mechanic and was frequently going up and down and crawling in small spaces as part of his job. (Continued on the next page) The examiner must provide a comprehensive medical rationale to support the opinion. In providing the requested opinion, the examiner must consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. López, 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.