Citation Nr: 21064229 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 18-07 169 DATE: October 19, 2021 REMANDED Entitlement to service connection for a neck disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1975 to September 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in September 2017 by a Department of Veterans Affairs (VA) Regional Office. In July 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. At such time, the Veteran waived Agency of Original Jurisdiction (AOJ) consideration of the evidence associated with the record since the issuance of the January 2018 statement of the case. 38 C.F.R. § 20.1305(c). Additionally, the undersigned held the record open for 60 days for the submission of additional evidence, which was received in August 2021. Entitlement to service connection for a neck disorder. The Veteran contends his current neck disorder, diagnosed as cervical spine degenerative disc disease (DDD) and degenerative joint disease (DJD) as reflected at a September 2017 VA examination, is directly related to his military service. Specifically, he reported that he was in motor vehicle accidents (MVAs) in 1983 and 1985 or 1987 where he was rear-ended by another vehicle. In this regard, his service treatment records (STRs) reflect that he was involved in a MVA in April 1983, and complained of neck pain in May 1983 and June 1983, which was assessed as persistent muscle inflammatory discomfort and muscle strain, respectively. However, such STRs are negative for any complaints, treatment, or diagnosis pertaining to the Veteran's reported second MVA. In this regard, the Board notes that he testified at the July 2021 Board hearing that he had been treated at Providence Hospital in Cincinnati following both MVAs, but was unable to obtain records as such facility had been demolished. However, in an August 2021 Independent Medical Examination from Dr. S.V., it was noted that the Veteran reported receiving treatment from the University of Cincinnati Hospital, but had not yet been successful in obtaining such records as he was informed that they may have been destroyed or archived as over 10 years had passed. Thus, as there is an indication that such records may still be available, the Board finds that a remand is necessary in order to attempt to obtain them. The Board further finds that a remand is necessary so as to obtain an addendum opinion addressing the etiology of the Veteran's neck disorder. In this regard, he was afforded a VA examination in September 2017, at which time the VA examiner opined that it was less likely than not that the Veteran's currently diagnosed cervical spine DDD and DJD was incurred in, caused by, or a result of the neck pain/MVA during service. In support thereof, he explained that, while the Veteran had neck pain in 1983 after an MVA, he reportedly had X-rays at a local hospital, which were negative. The examiner also explained that the Veteran's 1988 and 1994 Reports of Medical Examination were silent for a neck disorder; rather, the next notation of a neck condition was in December 2016, when the Veteran presented with neck pain for 3 weeks, and he was diagnosed with DDD and DJD in 2017, twenty years after service, which were most likely related to age-related degenerative change, generalized osteoarthritis in multiple joints, and chronic repetitive use over the lifetime. Thus, he concluded that the Veteran's neck muscle strain resolved without residuals as there was no evidence of chronicity of complaints or care of a neck condition from 1983 until December 2016. Additionally, while the Veteran submitted an Independent Medical Examination in August 2021 from Dr. S.V., such physician found that there was currently insufficient objective documentation available to support a relationship between the Veteran's current cervical spine DDD and DJD and the MVAs he was involved in service in the 1980's as there was a gap in the medical records between May 1983 and December 2016 and, thus, he could not state that it is as likely as not that his neck disorder is the result of his in-service MVAs. However, despite the lack of documented treatment, the Veteran testified that he has experienced a continuity of neck symptomatology since his first in-service MVA. Therefore, a remand is warranted to obtain an addendum opinion that addresses such matter. The matters are REMANDED for the following action: 1. The Veteran should be requested to submit or authorize VA to obtain his records from the University of Cincinnati Hospital from 1983 and 1985, or 1987, detailing treatment following his reported in-service MVAs. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained. Make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. 2. After all outstanding records have been associated with the record, return the record, to include a copy of this remand, to the VA examiner who conducted the September 2017 neck examination. If he is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a full review of the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the Veteran's neck disorder, currently diagnosed as cervical spine DDD and DJD, is related to his military service, to include his reported in-service MVAs in 1983, to include his documented complaints of neck pain, assessed as persistent muscle inflammatory discomfort and muscle strain, and in 1985 or 1987. In rendering his or her opinion, the examiner must consider the lay statements of record regarding the onset of the Veteran's neck disorder and the continuity of symptomatology of such disorder. He or she is also advised that the sole basis of a negative opinion cannot be the fact that the Veteran's STRs are silent as to a neck disorder after his 1983 MVA or a lack of post-service treatment records demonstrating a continuity of care. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Clark 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.