Citation Nr: 21066526 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 17-28 312 DATE: November 1, 2021 ORDER Service connection for a cervical spine disability is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, his cervical spine disability began during or is due to active service. CONCLUSION OF LAW The criteria for service connection for a cervical spine disability 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 duty from April 1988 to May 1998 and February 2003 to February 2004. This matter is on appeal form a May 2015 rating decision. The Veteran had a hearing before the undersigned Veterans Law Judge in October 2021. 1. Entitlement to service connection for a cervical spine disability. The Veteran asserts that his cervical spine disability started in 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). The May 2015 VA examination show the Veteran has a current diagnosis of multilevel herniated discs cervical spine with canal stenosis and secondary muscle strain. During service, the Veteran was seen for complaints of neck pain for months following reported injury. Thus, the question becomes whether the current disability is related to service. On this question there are probative opinions in favor of and against the claim. The evidence against the claim includes the May 2015 VA medical opinion by a VA physician. He found that careful review of the available medical record identified that while on active duty in 1994/1995 the Veteran experienced neck pain. An MRI at that time was negative and revealed no pathology. Many years later, a 2014 MRI identified multiple discogenic disease. He opined that the Veteran's current cervical spine disorder did not represent late complications of service-connected injury with negative cervical spine MRI. He opined that without evidence of continuity of symptoms and treatment pattern from the date of the injury through to the present, a causal nexus cannot be established. In contrast, an earlier May 2015 VA medical opinion, by a different VA medical opinion provider, the one who performed a physical examination of the Veteran, found that the Veteran had a history of neck injury during service in August 1994, that continued to hurt after many unsuccessful treatments. A December 1994 MRI showed mild alteration of curvature, while examination at VA examination showed multilevel herniated discs cervical spine with canal stenosis and secondary muscle strain. That VA examiner found it to be consistent with the chronic neck pain and mild alteration of curvature noted in the service treatment record. Also of record is a July 2021 private medical opinion by M.L., DNP. He opined that the Veteran's neck pain is service-connected and caused by a confirmed and documented active-duty neck injury that he suffered in August of 1994 while flying to Kenya on an active-duty mission. The Board notes that this opinion is not adequate as M.L. does not appear to have reviewed pertinent evidence of record. Specifically, M.L. opined that regarding the initial injury in service, "[a]s a healthcare provider and a peer review, I would have deemed it reasonable to obtain a cervical MRI for chronic pain and symptomology. However, an MRI was not ordered causing limitations for diagnosis and treatment." As discussed by the above VA medical opinion providers, the Veteran did receive an MRI of the cervical spine in service and the findings of such MRI were central to the VA medical opinions made. M.L. similarly indicates that such MRI findings would be important to forming a medical opinion regarding the Veteran's claimed cervical spine disability. The probative evidence in favor of the claim includes May 2015 VA examination opinion that found that the Veteran's multilevel herniated discs cervical spine with canal stenosis and secondary muscle strain was consistent with the chronic neck pain and mild alteration of curvature noted in the service treatment record. (Continued on the next page) The Board finds the evidence to at least be in equipoise as to whether the Veteran's current cervical spine disability is related to service. After resolving all doubt in favor of the Veteran, the Board finds that service connection for a cervical spine disability is warranted. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Lindio 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.