Citation Nr: 21064889
Decision Date: 10/21/21	Archive Date: 10/21/21

DOCKET NO. 19-26 548
DATE: October 21, 2021

REMANDED

Whether a separate rating is warranted for radiculopathy of the right upper extremity is remanded.

Whether a separate rating is warranted for radiculopathy of the left upper extremity is remanded.

REASONS FOR REMAND

The Veteran served on active duty from September 1956 to September 1958.

This case is on appeal from an August 2018 rating decision and was previously before the Board in August 2020.  

As noted in the August 2020 Board remand, although the RO denied "service connection" for these two issues in an October 2019 rating decision, the Board finds it has jurisdiction over the issues pursuant to Diagnostic Code 5242, Note 1, as part and parcel of the cervical spine arthritis rating claim.

Further, in the August 2020 remand the Board noted that in the January 2020 VA cervical spine examination, the examiner first provided that the Veteran does not have radicular pain or any signs of radiculopathy.  However, the examiner later stated in the medical opinion that the Veteran has associated objective neurologic abnormalities, as the Veteran has bilateral upper extremity cervical radiculopathy.  As such, the claim was remanded for a VA neurology examination for clarification on whether the Veteran has radiculopathy of the upper extremities and, if so, to ascertain the severity of the radiculopathy.

The Veteran underwent a VA neck examination in June 2021.  There were hypoactive reflexes (1+) throughout the upper extremities.  However, the examiner found that there was no diagnosis of right or left upper extremity radiculopathy.  In light of the abnormal neurological findings, further clarification is necessary.

This appeal is REMANDED for the following action:

1. Obtain any outstanding VA treatment records.

2. Obtain the Veteran's updated treatment records from Dr. Einsig at the Spine and Wellness Center.

3. Schedule the Veteran for a VA neurological examination to ascertain the current nature of any identified upper extremity neurological disabilities and any relationship to service-connected cervical spine condition.  The examiner must review the entire record.

First, the examiner should identify any abnormal neurological finding of the upper extremities and diagnose all upper extremity neurological disabilities.  In so doing, the examiner should explain the hypoactive reflexes (1+) throughout the Veteran's upper extremities on VA examination in June 2021.

Then, the examiner should opine whether it is at least as likely as not that any identified upper extremity neurological disability is an objective neurologic abnormality that is associated with the service-connected cervical spine condition.  The examiner should also assess the severity of any identified condition.

A complete rationale for all opinions expressed should be provided.

 

 

P. M. DILORENZO

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Buck Denton

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.