Citation Nr: 21070604 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 13-11 620 DATE: November 24, 2021 REMANDED Entitlement to service connection for a cervical spine disability is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from August 1994 to August 1998. These matters are before the Board of Veterans' Appeals (Board) on appeal from August 2013 and November 2014 rating decisions. In March 2016, a video conference hearing was held before the undersigned; a transcript is in the record. In April 2016, September 2017, February 2018, July 2018, and again (most recently) in December 2020, this matter was remanded for additional development. [A July 2021 rating decision granted a total disability rating based on individual unemployability (TDIU). Accordingly, that matter is no longer on appeal.] Entitlement to service connection for a cervical spine disability is remanded. The Board is aware that this matter has been remanded numerous times previously (and regrets the delay inherent with another remand). However, there has not been substantial compliance with previous remand directives, and corrective action still remains necessary. See Stegall v. West,11 Vet. App. 268, 271(1998). The Veteran's primary theory of entitlement is that his cervical spine disability is secondary to his service-connected low back disability. Pursuant to the December 2020 Board remand, an advisory medical opinion regarding the etiology of the Veteran's cervical spine disability was obtained in February 2021. Following review of the Veteran's claims file, the February 2021 consulting provider opined the claimed condition was less likely than not incurred in or caused by the claimed injury, event, or illness in-service, explaining, There is no evidence of a neck condition arising in service. Per the 2017 [Disability Benefits Questionnaire], the [V]eteran's own words place the onset of neck pain as 2003/2004. There is no separation [examination] or post-deployment [examination] available, but both pre-deployment questionnaires cited above are negative for neck conditions. Importantly, the general medical [Disability Benefits Questionnaire] dated [January 5, 2013] notes back conditions but is silent for neck conditions. It is unlikely a significant neck condition would have gone unreported at that time. As it was a general medical evaluation, it is also unlikely a significant neck condition would have been unnoted at [examination]. The private evaluation in March 2014 by Dr. E links the [V]eteran's neck conditions directly to his duties in service and to the lumbar spine conditions, citing a reflex mechanism. It clearly is not due to events in service for the above-stated reasons. Based on the neuroanatomy of the cervical and lumbar spine, there is no physiologic or anatomic mechanism to support that contention. Private physicians commonly hope to support their patient but do not understand the requirements of documentation, often rendering affirmative opinions without substantiation. The [V]eteran's current diagnosis, per the 2019 [Disability Benefits Questionnaire] is only IVDS. This diagnosis is not supported by the [examination] itself. There are no objective findings to support a diagnosis of radiculopathy or IVDS. Muscle strength and deep tendon reflexes are within normal limits. There is no documented diminution of sensory findings. The x-ray [October 30, 2015] showed minimal, age-appropriate [degenerative disc disease] at C5/C6. There is no [degenerative joint disease] of the facets identified. Degenerative disc disease is a naturally occurring condition due to natural disc desiccation with aging. It is not caused by muscle strain of the neck or lumbar spine. Lumbar spine conditions do not cause conditions of the cervical spine in general. This is established medical knowledge and practice, supported by standard orthopedic textbooks including Wheeless. There is no nexus in service, the [V]eteran himself places onset at least five years post-service and [degenerative disc disease] is a naturally occurring condition not caused by cervical or [lumbar] strain or conditions. Therefore, it is less likely than not that the [V]eteran's [degenerative disc disease] of the cervical spine had its onset in service or is due to conditions of the lumbar spine. This also applies to aggravation. Furthermore, there is no evidence to suggest aggravation of the [V]eteran's cervical spine condition beyond its natural course due to any cause. The natural course of degenerative spine disease is progression, often requiring medical or surgical intervention. If the [V]eteran has developed [degenerative joint disease] in the ensuing years, this rationale also applies. Should the [V]eteran develop objective findings to support a diagnosis of IVDS or radiculopathy, they are likely due to degenerative spine disease, and this rationale still applies. Although the Board finds the VA consulting provider has given adequate rationale in opining that the Veteran's cervical spine degenerative disc disease is not caused by his service-connected lumbar spine disability, the rationale does not explain why his cervical spine degenerative disc disease is not aggravated beyond its natural progression by his service-connected lumbar spine disability. Instead, following his rationale regarding causation, the VA examiner summarily stated, "this also applies to aggravation" without any explanation why the cervical spine degenerative disc disease is not aggravated by the Veteran's service-connected lumbar spine disability. The December 2020 Board remand directives instructed the VA provider "if the response to (is it at least as likely as not that the neck disability was aggravated by the Veteran's service-connected back disability) is no - and the explanation is because the neck disability has not increased in severity, cite to the clinical findings that support that conclusion. If the response is no - because a back disability would not impact a neck disability, the rationale should address Dr. E's statement indicating that the Veteran's neck spasms have been "consequential" to his back disability." The February 2021 VA provider did not cite to clinical findings that support his conclusion and did not address Dr. E's statement indicating that the Veteran's neck spasms have been "consequential" to his back disability (other than discussing motive for the statement, i.e., did not explain why Dr. E's statement was inconsistent factual data of record). Therefore, the opinion February 2021 provided is incomplete, and another remand for development of evidence is necessary. See Stegall, supra. The matters are REMANDED for the following action: Arrange for the Veteran's claims file to be returned to the February 2021 consulting provider or forwarded to an appropriate clinician (e.g., in orthopedics) for re-review considering the explanation above, and an addendum advisory opinion that fully addresses whether it is at least as likely as not that his cervical spine disability was aggravated by his service-connected lumbar spine disability (beyond natural progression)? The opinion must include responses to the following: 1. Has the Veteran's cervical spine disability increased in severity since its initial diagnosis? Cite to the clinical data that support the response. 2. If an increase in severity of the cervical spine disability is found shown, is all of the increase due to natural progression. Cite to the factual data and medical principles that support the conclusion. 3. If all of any increase in severity of the cervical spine disability found is not due to natural progression, was any of it due to aggravation by the Veteran's service-connected lumbar spine disability? The response should specifically address the Dr. E's statement indicating that the Veteran's neck spasms (a specific manifestation of the cervical spine disability) are consequential (secondary) to his service connected lumbar spine disability (express agreement or disagreement with that statement, explaining -citing to medical principles and clinical data, rather than Dr. E's motivation the reasoning for the agreement or disagreement). All opinions must include rationale that cites to supporting factual data and medical principles. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Griffith 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.