Citation Nr: 21069268 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 15-24 671 DATE: November 18, 2021 ORDER Entitlement to service connection for cervical spine injury residuals including degenerative disc disease and intervertebral disc syndrome is granted. Entitlement to service connection for left shoulder neurological disability is granted. FINDINGS OF FACT 1. Cervical spine injury residuals including degenerative disc disease and intervertebral disc syndrome originated during active service. 2. A left shoulder neurological disability originated during active service. CONCLUSIONS OF LAW 1. The criteria for service connection for cervical spine injury residuals including degenerative disc disease and intervertebral disc syndrome have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for left shoulder neurological disability have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from November 1976 to November 1979. In June 2019, the Board of Veterans' Appeals (Board) denied service connection for a left shoulder disability. The Veteran subsequently appealed to the United States Court of Appeals for Veterans Claims (Court). In February 2020, the Court granted the Parties' Joint Motion for Remand; vacated the June 2019 Board decision; and remanded the appeal to the Board for additional action including consideration of whether the issue of service connection for a cervical spine disability is before the Board. In August 2020, the Board remanded the issues of service connection for a cervical spine disability and a left shoulder disability to the Agency of Original Jurisdiction for additional development. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 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). 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). Cervical Spine The service treatment records do not refer to a cervical spine disability. The documentation does reflect that the Veteran sustained head trauma. A September 1977 treatment record states that the Veteran was wrestling with a friend at a Kentucky Fried Chicken restaurant and hit his head, vomited, and passed out. A July 1978 states that the Veteran was involved in a motor vehicle accident. A February 2021 evaluation from M. Shoag, M.D., states that he had reviewed the claims record. The doctor noted that: the Veteran had been diagnosed with a cervical spine disc disorder with myelopathy; "while in the service, Veteran is recorded as sustaining injuries or experiencing pain to his cervical spine/left shoulder on three occasions as identified above;" "the mechanism of injury was that this gentleman's head was hit up against a brick wall per the information within the record;" and "this was not a mild injury to say the least and the severity of same cannot be minimized." The examiner concluded that "this gentleman's cervical spine disease is as least as likely as not service connected." The report of a March 2021 spine examination conducted for VA states that the Veteran was diagnosed with cervical spine degenerative disc disease and intervertebral disc syndrome. A September 2021 written statement from Dr. Shoag clarifies that: "to be very clear, this Veteran has suffered and continues to suffer from three neurological illnesses originating from a cervical spine injury which he suffered while in the service;" "these include 1.) severe radiculopathy of his left shoulder with severe loss of function that remains ongoing; 2.) bowel incontinence and 3.) emesis post injury;" and "the latter two are within a reasonable degree of medical certainty and probability indicative of severe trauma to his cervical spine and associated with neurologic difficulty." The doctor opined that, "in conclusion, this gentleman suffered a significant injury to his cervical spine while in the service which has caused significant degenerative conditions as time evolved, which is very typical." The service treatment records reflect that the Veteran sustained a head trauma when wrestling and lost consciousness. The Veteran has been diagnosed by a VA examiner with cervical spine degenerative disc disease and intervertebral disc syndrome. Dr. Shoag has attributed the diagnosed cervical spine disability to the in service trauma. The Board finds that the evidence is in at least equipoise as to whether the diagnosed cervical spine disability originated during active service. Therefore, service connection for cervical spine injury residuals including degenerative disc disease and intervertebral disc syndrome is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Left Shoulder The service treatment records convey that the Veteran was seen for left shoulder trauma. A March 1979 treatment record states that the Veteran complained of left shoulder pain after lifting a grill in the mess hall. The Veteran was diagnosed with "muscle strain/sprain." (Continued on the next page) The February 2021 evaluation from Dr. Shoag, M.D., indicates that: the "Veteran has been seen by a number of medical providers who have noted in 2011, 2014, 2015, and 2016 that his shoulder disability and damage may well be in large part related to his cervical pathology;" "it is a known fact that the nervous system innervation to the shoulder girdle, the rotator cuff area, and the biceps are from nerves that exit through the cervical spine;" and "any damage to those nerves, nerve roots or to the cervical cord from which those nerves emanate are much more likely than not to cause shoulder damage, neurologic damage to the shoulder itself as well loss of function, strength and mobility. The doctor concluded that "given that this gentleman's cervical spine disease is as least as likely as not service connected, it is therefore similarly as least as likely as not that his shoulder pathology is service connected." The service treatment records reflect that the Veteran sustained left shoulder trauma. Dr. Shoag has diagnosed the Veteran was a left shoulder neurological disability attributed to the documented in service trauma. The Board finds that the evidence is in at least equipoise as to whether the diagnosed left shoulder neurological disability originated during active service. Therefore, service connection for a left shoulder neurological disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Emily A. Kotroco 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.