Citation Nr: 21069548 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 15-31 928 DATE: November 18, 2021 REMANDED Entitlement to an initial rating in excess of 20 percent for cervical spine strain is remanded. REASONS FOR REMAND The Veteran had active service from July 1993 to July 1996 and from September 2004 to January 2006. He served in Iraq. Entitlement to an initial rating in excess of 20 percent for cervical spine strain is remanded. The Veteran asserts that an initial rating in excess of 20 percent for cervical spine strain is warranted as the disability is productive of significant physical impairment. The report of a July 2015 Department of Veterans Affairs (VA) cervical spine examination states that the Veteran exhibited a range of motion of the cervical spine of forward flexion to 45 degrees, extension to 35 degrees, lateral flexion to 45 degrees with pain, bilaterally, and lateral rotation to 80 degrees, bilaterally. In his September 2015 Appeal to the Board, VA Form 9, the Veteran indicated that he experienced severe functional limitation of the ability to turn his head which impacted his ability to safely drive his car. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Given the reported cervical spine functional impairment and in light of the elapse of over six years since the last VA examination, the Board of Veterans' Appeals (Board) finds that further VA cervical spine evaluation is needed. Clinical documentation dated after January 2020 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, this matter is REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated the service connected cervical spine disability. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after January 2020. 3. Schedule the Veteran for a VA spine examination conducted by a medical doctor to assist in determining both the current nature and severity of the service connected cervical spine strain. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should provide the following opinions: (a) Provide ranges of motion for passive and active motion of the cervical spine. The examiner should indicate the degree of cervical spine motion at which any observed pain begins. The examiner should state whether there is any additional loss of cervical spine function due to painful motion, weakened motion, excess motion, fatigability, or incoordination. (b) Indicate to what extent, the Veteran experiences functional loss of the cervical spine due to pain or any other symptoms during flare ups or with repeated use. (c) Note any incapacitating episodes associated with the cervical spine disability and the duration. An incapacitating episode is a period of acute signs and symptoms that requires bed rest prescribed by a physician and treatment by a physician. (d) State whether or not there is any ankylosis of the spine or any segment of the spine. (e) The examiner should provide an opinion as to the impact of the cervical spine disability on the Veteran's vocational pursuits. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Marsdale 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.