Citation Nr: 21068930 Decision Date: 11/16/21 Archive Date: 11/15/21 DOCKET NO. 17-48 343 DATE: November 16, 2021 ORDER Entitlement to service connection for trigeminal neuralgia is granted. REMANDED Entitlement to service connection for right hand, essential tremor is remanded. Entitlement to service connection for left hand, essential tremor is remanded. FINDINGS OF FACT Resolving any doubt in the Veteran's favor, his current trigeminal neuralgia began during active service. CONCLUSIONS OF LAW The criteria for service connection for trigeminal neuralgia are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from June 1980 to June 1983, and in the U.S. Coast Guard from January 1985 to July 2003. These matters are before the Board of Veterans' Appeals (Board) on appeal from a December 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2019, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge; a transcript is of record. In February 2020, the Board remanded the claim for further development. There has been substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for trigeminal neuralgia is granted. The Veteran contends that his current trigeminal neuralgia onset during active service. See November 2019 Board hearing transcript at 3, 15. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). As an initial matter, the Board had previously found that although the Veteran sustained a head injury prior to his first period of active duty, his current trigeminal neuralgia did not pre-exist entrance either period of active duty. See February 2020 Board decision at 2-3. The Board noted that the Veteran's July 1979 entrance examination into the U.S. Army and August 1984 enlistment examination for the U.S. Coast Guard both showed a normal clinical evaluation of the neurologic system and did not note such a condition. Thus, the presumption of soundness attached with respect to both periods of service. 38 U.S.C. § 1111; 38C.F.R. §3.304(b). The question remaining for the Board is whether the Veteran's trigeminal neuralgia began during service or is at least as likely as not related to an in-service injury, event, or disease. The Veteran's July 1979 enlistment examination for the Army revealed a normal neurologic system. In a June 1983 form, he elected not to undergo a medical examination for separation. The Veteran began his second period of active duty, in the U.S. Coast Guard, in January 1985. His August 1984 enlistment exam report showed a normal neurologic system. In an August 1984 report of medical history, he marked "yes" for head injury and "no" for everything else; he annotated "received slight concussion and 4 stitches to forward right cerebral area of cranium due to bicycle accident during approx. Jun 1977." A February 1988 service treatment record (STR) noted complaints of a twitching sensation in the posterior portion of right side of his head, causing his right hand to twitch with a heavy feeling in both feet. He reported disorientation when this occurred. The assessment was "? mild seizure / muscle spasm." A November 1988 STR noted his gun kicked back and struck his right forehead. He reported there was no loss of consciousness but felt worried afterward. The record revealed a finding of "laceration right eyebrow, head trauma." Another November 1988 STR noted the incident where the Veteran was struck with telescopic sight over right eyebrow. The record indicated the X-ray was negative for head or facial fracture. A January 1989 report of medical examination noted an abnormal neurologic system, but indicated there was "no motor or sensory deficit." A January 1989 report of medical history shows the Veteran marked "yes" for a head injury and nervous trouble, and "don't know" for neuritis. An October 1992 STR noted complaints of undue sensitivity to palpation/pressure and severe sharp pain for three months localized to right frontal temporal area. The record noted no recent trauma but lacerations in the past. The provisional diagnosis was localized severe pain to palpation, right frontal-temporal site, of unknown etiology. A November 1992 STR noted a complaint of continued pain in frontal-temporal lobe; the assessment was pain in frontal-temporal site. In a November 1992 private neurology record from Dr. E.S., the Veteran reported intermittent electric shock-like feelings in his right forehead that was similar to a toothache. He stated the symptom is brought on by a light touch at the hairline over his right forehead. He also reported numbness and twitching of the muscles in his right forehead. The symptoms have been present three and a half months and are getting worse. The pain usually occurred on triggering and rarely spontaneously. Dr. E.S. noted the Veteran did not have any history of neurological problem other than familial tremor. Dr. E.S. noted the Veteran had a history of striking his head in the back of a van in 1975, and being hit over the right eye with a rifle scope in 1988. The Veteran was diagnosed with right trigeminal neuralgia in the first distribution of the trigeminal nerve. No etiology was given. A November 1992 MRI of the brain noted right trigeminal neuralgia, rule out cerebral proliferative angiopathy (CPA). A November 1992 STR noted the Veteran complained of unspecified right-sided facial muscle twitching accompanied by panic-like attacks in which he felt tense and fearful. He reported several episodes in the last 30 days and that they are increasing in frequency. The STR record noted he has been diagnosed with right trigeminal neuralgia in November 1992. The provisional diagnosis was "r/o [rule out] seizure disorder." Another November 1992 STR noted the Veteran is here for follow-up neurology consultation. It noted pain was of increasing severity that was radiating to temporal site. On observation, tenderness over right temporal area and right swollen right eyelid were noted. The assessment was right trigeminal neuralgia of unknown etiology. A December 1992 STR noted persistent trigeminal neuralgia and nicotine dependence. A January 1993 STR noted trigeminal neuralgia and tobacco cessation. In a December 1993 report of medical history, he marked "yes" to head injury, nervous trouble, and periods of unconsciousness. A handwritten note indicates the Veteran hit a van on his bicycle when he was about 13 years old, was knocked unconscious for about three seconds, and had three stitches. The corresponding December 1993 medical examination noted a normal neurologic system. A June 1997 STR noted history of trigeminal neuralgia and right sided facial pain. The Veteran reported a strange sensation on right side of face of a muscle twitch sensation. He reported the sensations occur for no reason, and that he has had several in last 30 days. He reported he has not experienced any increase in stress at home or at work. The assessment was "R/O seizure disorder." He was referred to neurology. A June 1997 STR noted the Veteran presented for evaluation of possible trigeminal neuralgia. It noted the Veteran was a patient with a past history of trigeminal neuralgia in 1992, which had resolved without recurrence. The Veteran reported one episode of the muscle of the right side of the face which lasted 20-30 minutes. The assessment was anxiety with pain and no evidence trigeminal neuralgia. In the October 2002 separation report of medical history, the Veteran marked "yes" for head injury and nervous trouble of any sort. The corresponding October 2002 retirement exam report shows an abnormal neurologic system; the clinician annotated, "resting tremor o/w [otherwise] wnl [within normal limits]." At the August 2016 VA examination, the Veteran was diagnosed with trigeminal neuralgia as of 1994. He reported it onset in service in 1994 with pain over the right forehead. The examiner did not opine on whether his trigeminal neuralgia was related to service. At the November 2019 Board hearing, the Veteran testified that during Coast Guard service, he noticed severe pain when anything touched his head. He stated he was seen by a neurologist and was diagnosed with trigeminal neuralgia. He stated the doctor told him the cause is not known. He reported he has had the condition since service, and is currently seen by Dr. G.G. about every 6 months. He also stated that while he had a pre-service head injury, it was nothing other than a bicycle hitting the back of a van, and getting three stitches above the right eye. He reported he did not stay overnight at the hospital, and that he did not have a concussion or traumatic brain injury. He added the area of the head injury was different from his current trigeminal neuralgia. In a November 2019 private record, neurologist G.G. diagnosed trigeminal neuralgia. Dr. G.G. noted that the trigeminal neuralgia began during the Veteran's time in the Coast Guard. Dr. G.G. commented it was not related to a head injury. A rationale was not provided. Pursuant to the November 2019 Board remand, a VA examination was provided to the Veteran in August 2020. The opinion and addendum were provided in August 2020 and September 2020, respectively. The Veteran was diagnosed with trigeminal neuralgia. He reported the condition began in 1985 with pain in the front of his forehead. He stated he did not have any trauma, and that an MRI of the brain was negative. He noted he now has tenderness to the touch, such as touching his forehead lightly or the wind blowing. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted the following medical records to support the negative nexus opinion: per the Veteran's own account in the August 1984 report of medical history, he had a concussion with loss of consciousness secondary to head trauma that required stitches due to a bicycle accident in 1977; an April 1988 STR noting headaches on the right side of head, which was the same location of head injury as child; the December 1993 report of medical history noted a head injury with loss of consciousness at age 13; and reporting of headaches in the November 2019 clinical note by Dr. G.G. which suggest the current headache is not due to active service. Upon review of the record, resolving any reasonable doubt in the Veteran's favor, the Board finds the evidence to at least be in equipoise as to whether the current trigeminal neuralgia began during or is related to active service. The August 2016 and August 2020 examination reports show a current diagnosis of trigeminal neuralgia. The STRs show complaints, diagnosis, and treatment for trigeminal neuralgia during active service. Notably, this condition was not diagnosed prior to service entrance, nor is there any evidence of subjective complaints of the type of symptomatology that was first reported in service. Thus, the first and second elements for service connection are met. The question that remains is the nexus. The record includes opinions in favor of the claim and against the claim. The August 2020 VA examiner opined that the trigeminal neuralgia is unrelated to service. The examiner's opinion is probative because he reviewed the claims file and relevant evidence. The examiner also provided a rationale that identified relevant evidence. He explained, in pertinent part, that STRs show headaches in the same location of pre-service head injury during which the Veteran reportedly sustained a concussion with loss of consciousness and required stitches. He also indicated that Dr. G.G.'s treatment record further suggests the current 'HA" is due to service events, but did not expound upon that finding. Conversely, Dr. G.G.'s opinion that the Veteran's current trigeminal neuralgia began during the Veteran's time in the Coast Guard is less probative than the VA opinion because it was not supported by a rationale and there is no indication that Dr. G.G. reviewed the claims file such that he was adequately familiar with the Veteran's pertinent clinical history. Nevertheless, the Board observes that the Veteran's STRs do show complaints and a diagnosis trigeminal neuralgia beginning during his second period of service, which was nearly years after his 1977 bicycle accident, with no intervening sequelae reported or clinically observed. The VA examiner in 2020 did not discuss the significance, if any, of the nearly eight-year period without complaint of manifestations of a neurologic disorder consistent with trigeminal neuralgia. Moreover, the Veteran has generally asserted that he has continued to have similar symptoms following service discharge. The examiner did not discuss this aspect of the lay evidence either. The Board has not based the conclusion reached in this case on its own unsubstantiated medical conclusions. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Rather, in viewing the totality of the available evidence, the Board finds that the record contains reasonably sufficient evidence to find that the current disorder onset in service. Indeed, service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Resolving any reasonable doubt in favor of the Veteran, Accordingly, service connection for trigeminal neuralgia is granted. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.303(a), (d). REASONS FOR REMAND 1. Entitlement to service connection for right hand, essential tremor is remanded. 2. Entitlement to service connection for left hand, essential tremor is remanded. In a November 2019 record, Dr. G.G., a private clinician, diagnosed essential tremor. Dr. G.G. stated that this is the familial form and is not related to a head injury. He also stated, "Service related anxiety has worsened symptoms at times. Under acceptable control with low dose propranolol." A rationale was not provided. To the extent this opinion suggests there is a causal relationship between the Veteran's claimed bilateral hand tremor and his service-connected panic disorder with agoraphobia (also claimed as generalized anxiety disorder), the record does not contain sufficient information for the Board to make a determination regarding aggravation at this time. The appeal is remanded for a supplemental medical opinion. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's claimed bilateral hand tremor is at least as likely as not either: a) proximately due to service-connected panic disorder with agoraphobia; or, b) aggravated beyond its natural progression by his service-connected panic disorder with agoraphobia. A rationale must be provided. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Jake Choi, Associate 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.