Citation Nr: 21071087 Decision Date: 11/29/21 Archive Date: 11/29/21 DOCKET NO. 17-38 139 DATE: November 29, 2021 ORDER Entitlement to service connection for a low back disorder, to include on a secondary basis, is denied. Entitlement to service connection for bilateral upper extremity neuropathy, to include on a secondary basis, is denied. FINDINGS OF FACT 1. The Veteran's current low back disorder was not manifested during service or within one year of separation from service, is not related to any event during service, and is not secondary to a service-connected disability. 2. The Veteran's bilateral upper extremity neuropathy did not have its onset during service or within one year of separation from service, is not related to any event during service, and is not secondary to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a low back disorder, to include on a secondary basis, have not been met. 38 U.S.C. §§ 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for entitlement to service connection for bilateral upper extremity neuropathy, to include on a secondary basis, have not been met. 38 U.S.C. §§ 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1976 to June 1980. These matters come before the Board of Veterans' Appeals (Board) on appeal from November 2014 and August 2015 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the August 2015 rating decision adjudicated the issues of low back disability and right and left upper extremity neuropathy as claims to reopen. See August 2015 Rating Decision Narrative. However, a notice of disagreement that encompasses these issues was submitted in September 2015, which was within one year from the November 2014 rating decision that initially denied the issues. As such, the Board finds that the November 2014 rating decision is not final, so these issues are recharacterized as claims for service connection. The Veteran testified at a hearing before the undersigned in March 2020. The transcript is of record. In June 2020, the Board remanded these matters. Service Connection Service connection will be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent evidence showing, (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7Vet. App.at 448 (1995). 1. Entitlement to service connection for a low back disorder, to include on a secondary basis. The Veteran contends his low back disorder is either due to a tick bite he received during service, which he believed caused Lyme disease and led to his disorder, or a cyst that was removed from the tailbone region during service. See March 2020 Hearing Transcript. Regarding direct service connection, the Veteran's service treatment records from July and August 1979 indicated he had a tick removed in June 1979 by non-medical personnel and that afterwards he developed redness on his right thigh. An initial assessment was possible infection or blood poisoning and then after further evaluation he had a provisional diagnosis of tick bite with erythema. The cyst on his coccyx bone was noted in January 1980 and had been present for two weeks before he sought treatment. The assessment was peri rectal abcess and it was removed the next day. The Board also notes that his service treatment records are silent for any complaints or findings of a low back disorder. See July 2014 STR Medical. In April 1980, the Veteran elected to not have a separation examination and a physician who reviewed his medical records determined that a medical examination was not required. See April 1980 Military Personnel Record. Although no low back complaints had been noted in the Veteran's post-service medical records when he first started receiving VA treatment, an October 2014 VA medical record showed he had an MRI of the lumbar spine due to complaints of numbness and tingling in his extremities; the impression was degenerative disc disease without spinal stenosis, and mild bilateral neural foraminal narrowing at L4-S1. See June 2015 CAPRI records. Service connection cannot be established on a presumptive basis for arthritis as a chronic disease since there is no evidence that it manifested during service or during the first year after service. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (2013). While the record confirms the incidents in service, specifically the tick bite and cyst, and the presence of a current low back disorder, there is not probative nexus evidence of record that supports the Veteran's assertion that his current disorder is related to those events in service. In March 2020, the Veteran submitted a statement from a private physician that it was his professional opinion that the Veteran's clinical symptoms and signs may be due to Lyme disease. See March 2020 Medical Treatment Record Non-Government Facility. This opinion lacks any meaningful probative value due to its vagueness, lack of rationale, and inconsistency with the other evidence of record. It is vague because it did not identify the Veteran's low back disorder and the statement conflicted with the medical evidence of record that showed the Veteran did not have Lyme disease. See November 2014 treatment record in June 2015 CAPRI records. On June 2015 VA examination, the clinician stated that the Veteran did not meet the clinical diagnostic criteria for any diagnosis related to tick bites. She also opined that the Veteran's low back disorder was less likely than not caused by an in-service event. She reasoned that the Veteran did not meet the clinical criteria for any non-degenerative arthritis (including inflammatory, autoimmune crystalline and infectious arthritis) and/or dysbaric osteonecrosis at this time. He did have known degenerative arthritis of the lumbar spine, but this was age-related. Degenerative arthritis of the lumbar spine was not known to be related to tick bites or tick removal. See June 2015 C&P Exam. A more recent VA opinion in August 2020 also resulted in unfavorable opinions. The Veteran was diagnosed with having degenerative joint disease (DJD) of the lumbar spine and there was no indication of any back condition that caused compression of the nerves or the spinal cord, which eliminated that as a possible cause of any neurologic changes. Spinal DJD was related to age and a genetic predilection. There was no evidence of a chronic back condition in service or proximate to service. The Veteran's mild DJD was not diagnosed until 2016, a span of greater than 30 years since service. As DJD was a natural condition, commonly arising without antecedent injury or spinal condition, it was unlikely to be due to events in service. Greater than 50 percent of men over the age of 50 will have degenerative spine disease. Therefore, the Veteran's DJD was less likely than not due to events in service, and more likely than not arose proximate to the diagnosis in 2016. It was not related to the pilonidal cyst excision while in service. The anatomical locations and pathophysiology were different. Pilonidal cysts are not considered a back condition, per se, but arise in the soft tissue overlying the sacral/coccygeal areas. See August 2020 C&P Exam. The VA opinions are highly probative and persuasive since they are adequately supported, consistent with the record, and appeared to be based on generally accepted medical principles. As for secondary service connection, the Veteran's only service-connected disabilities are tinnitus and hearing loss, and there is no evidence to suggest that either disability caused or aggravated the Veteran's low back disorder. For the reasons stated, a preponderance of the evidence is against the claim, so service connection is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for bilateral upper extremity neuropathy, to include on a secondary basis. The Veteran also contends his bilateral upper extremity neuropathy is related to the tick bite during service. See March 2020 Hearing Transcript. In August 2013, the Veteran reported having a recent onset of multiple symptoms that included numbness to both arms. He had similar complaints in May 2014 and July 2014. In August 2014, he had an MRI of the cervical spine due to numbness in the upper extremities from the shoulders to the hands that was worse with lifting. The impression was mild degenerative changes; there was no canal stenosis, cord compression, or significant neuroforaminal narrowing. In September 2014, he reported these symptoms had been present for approximately two years. See July 2014 and June 2015 CAPRI records. A September 2014 EMG consult showed he was referred due to severe numbness of both hands and forearms bilaterally. The clinician noted that in 2002 the Veteran was diagnosed with bilateral carpal tunnel syndrome and underwent carpal tunnel release surgery on the left side. This surgery failed to relieve any symptoms of his left hand. In 2012, he had fibrillation, which was his first episode, and ever since that event he had been having severe aggravation of numbness of all five fingers of both hands moving up to his elbows on both sides. The impression was abnormal electrodiagnostic study consistent with persistent EMG abnormality of focal median nerve compression neuropathy at the wrist on both sides, carpal tunnel syndrome. The abnormally delayed sensory nerve latency of both ulnar nerves was consistent with compression neuropathy of ulnar nerve at the wrists, Guyon's canal on both sides. There was no electrodiagnostic evidence of the cervical radiculopathy on right side. See June 2015 CAPRI records. Service connection is not available on a presumptive basis as an organic disease of the nervous system since there was no evidence of the Veteran's neuropathy during service or the first year after separation from service. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (2013). While the record confirms the Veteran had a tick bite during service and that he currently has bilateral upper extremity neuropathy, there is not probative nexus evidence of record that supports the Veteran's assertion that his neuropathy is related to service, to include the tick bite. In April 2015, an infectious disease physician opined based on the Veteran's reported history of prior tick bites, medical records, lab work, and a negative screening test for Lyme disease, that it was unlikely that the Veteran had Lyme disease that caused his neuropathy. See June 2015 CAPRI records. On June 2015 VA examination, the clinician found that the Veteran did not meet clinical diagnostic criteria for any diagnosis related to tick bites and that the procedure for removal of a tick did not result in polyneuropathy. The Veteran did not have polyneuropathy until about 2012 when he reported it to his providers at the VA Medical Center; therefore, his polyneuropathy was less likely than not (less than 50 percent or greater probability) caused by the tick bite/removal during service. See June 2015 C&P Exam. On August 2020 VA examination, the clinician opined that the Veteran did not have a service-connected disability that would independently impact the carpal tunnel and ulnar tunnel syndromes. Instead, they were due to local compression of the respective nerves, and the wrist bilaterally. There was no physiologic or anatomic mechanism by which any other service-connected disability would impact these nerve palsies, in terms of cause or aggravation. This was accepted medical knowledge and practice, supported by standard textbooks, such as Wheeless. The upper extremity neuropathies were due to impingement of the ulnar nerve and median nerve at the wrist, bilaterally, as documented on the EMG in 2014. This was consistent with carpal tunnel syndrome and ulnar tunnel syndrome. This was due to nerve compression at the wrist in these anatomical areas. There was no evidence of carpal tunnel syndrome or ulnar tunnel syndrome while in service or proximate to service. The onset appears to be late 2013 or 2014. This was a span of greater than 30 years since service. The clinician added that it was unlikely those two bilateral nerve palsies would not have become manifest and become more pronounced and severe within that time if there had had been a nexus to service. Therefore, it is less likely than not that the Veteran's carpal tunnel and ulnar tunnel syndromes of the bilateral wrist had their nexus in service or were due to events in service. See August 2020 C&P Exam. (Continued on the next page) The above opinions are against the claim and the clinicians adequately explained the basis of the opinions. The Board finds these opinions are probative and persuasive. As previously discussed, the March 2020 private opinion in which the physician stated that the Veteran's clinical symptoms and signs may be due to Lyme disease was too vague, not supported by a rationale, and inconsistent with the record and, therefore, lacked any meaningful probative value. See March 2020 Medical Treatment Record Non-Government Facility. For the reasons stated, a preponderance of the evidence is against the claim, so service connection is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Bredehorst, 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.