Citation Nr: 21069394
Decision Date: 11/18/21	Archive Date: 11/18/21

DOCKET NO. 16-08 257
DATE: November 18, 2021

REMANDED

Entitlement to service connection for a cervical spine disorder is remanded.

REASONS FOR REMAND

The Veteran served honorably on active duty in the U.S. Air Force from June 1972 until October 1977, and in the U.S. Army from November 1990 to June 1991, February 2003 to January 2004, and May 2009 to May 2012. The Veteran had additional service in the National Guard and Reserves. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).

The matter was remanded by the Board in April 2019 and September 2020 and has been returned for further appellate review. Unfortunately, remand is again necessary.

1. Entitlement to service connection for a cervical spine disorder is remanded.

This issue is remanded to secure an adequate medical opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Here, the opinion of record fails to address all facts and is not supported by a thorough rationale.

In this case, the service treatment records (STRs) include an April 1991 report of medical examination noting a diagnosis of cervical sprain, and in the accompanying report of medical history the Veteran endorsed recurrent neck stiffness. June 2007 VA x-rays of the cervical spine show extensive degenerative disc disease with neural foraminal encroachment in the cervical spine. 

VA obtained a medical examination and opinion in August 2021. That examiner opined that diagnosed degenerative disc disease of the cervical spine was not related to the Veteran's active duty service because it had onset in June 2007, when the Veteran was not on active duty. The examiner did not address the April 1991 report of medical examination noting cervical strain and the testimony of recurrent neck stiffness. Further, it is unlikely that extensive degenerative disc disease spontaneously manifested in June 2007 when the degree of that disease was already extensive. On remand, VA must obtain an adequate medical opinion that addresses the in-service symptoms of recurrent neck stiffness diagnosed as cervical strain, and whether degenerative disc disease could have manifested earlier but remained largely asymptomatic. 

The matters are REMANDED for the following action:

1. Obtain an addendum opinion regarding the etiology of the cervical spine disorder from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided.  

(a.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that a cervical spine disorder had onset in, or is otherwise related to, active service.  

(b.) The examiner must address the April 1991 report of medical examination noting a diagnosis of cervical strain, and the April 1991 report of medical history noting recurrent neck stiffness.

(c.) The examiner is requested to comment on whether degenerative disc disease could have manifested earlier but remained largely asymptomatic in light of the already extensive disease reported on the June 2007 VA X-ray report.

 

 

M. C. WILSON

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	C. Smith, 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.