Citation Nr: 21071791 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 16-34 578 DATE: December 1, 2021 REMANDED Entitlement to service connection for peripheral neuropathy of the right upper extremity is remanded. Entitlement to service connection for peripheral neuropathy of the left upper extremity is remanded. Entitlement to service connection for peripheral neuropathy of the right lower extremity is remanded. Entitlement to service connection for peripheral neuropathy of the left lower extremity is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from September 1965 to January 1969. These matters come before the Board of Veterans' Appeals (Board) on appeal of a decision issued by the Department of Veterans Affairs (VA), and have been advanced on the Board's docket pursuant to 38 U.S.C. § 7107. These matters were previously remanded in January 2020, October 2020, and August 2021. In August 2021, the Board asked the agency of original jurisdiction (AOJ) to obtain a medical opinion considering relevant evidence as indicated in a prior Board remand and providing an adequate rationale for the question of a nexus between the Veteran's neuropathy and exposure to herbicide agents. The AOJ obtained medical opinions in September 2021. Regrettably, the Board finds that the opinions do not substantially comply with the prior remand directives and further clarification is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The September 2021 VA medical opinion from Dr. P.G. found that it is at least as likely as not that the Veteran's: "[p]eripheral neuropathy is related to military service but less likely than not due to Agent Orange. The rigors of his military service, to include participating in the Vietnam War caused his neck disability that is source of his peripheral neuropathy. MRI findings for lower back show multilevel degenerative changes with multilevel spinal canal stenosis resulting in nerve compression and cervical fusion causing his...peripheral neuropathy. Rigors of his Vietnam War service included carrying a minimum of 85 lbs of combat gear. Veteran's height of five foot 9.25 inches and weight of 169 lbs at discharge is of a medium stature for males. Carrying that much weight upon his person was a burden to his spine causing degeneration and compressed nerve roots resulting in his neuropathy as evidenced by his MRIs, as his level of degeneration is advanced compared to others in his age group." Dr. P.G. later submitted an additional opinion echoing his findings that the Veteran's military service caused back and neck injuries, which led to peripheral neuropathy. These opinions are not sufficient. First, the Veteran is not service-connected for a lumbar or cervical spine disability. Service connection for cervical spine disability was denied in an unappealed April 2018 rating decision. For that reason, service connection may not be granted on a secondary basis for peripheral neuropathy caused by any cervical spine disability. 38 C.F.R. § 3.310. If the Veteran wishes to resubmit a claim for service connection for a cervical spine disability, he remains free to do so by submitting the appropriate application form as prescribed by the Secretary. Second, the opinion did not provide any rationale for its conclusion that the Veteran's peripheral neuropathy is not related to exposure to herbicide agents. Third, although Dr. P.G. listed some of the evidence raised by the Board in the prior directives, it again appears that he did not address all of the relevant evidence as specifically requested in the prior remand directives, including the October 2013 VA treatment record and the June 2017 brief. See BVA Decision, August 2021. Further remand is necessary to ensure an adequate medical opinion considering relevant theories of entitlement and addressing relevant evidence. The Board sincerely regrets the delay occasioned by multiple remands and appreciates the Veteran's patience as VA works to fulfill its statutory obligation to assist him in obtaining evidence necessary to support his claims for compensation. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from a clinician other than Dr. P.G. The clinician is asked to review the claims file and to opine on the following: (a) Is it at least as likely as not that the Veteran's peripheral neuropathy of the bilateral upper or lower extremities began during or is causally related to service, to include exposure to herbicide agents? (b) Is it at least as likely as not that the Veteran's peripheral neuropathy had onset within a year of discharge from active military service? A complete rationale should be provided for all opinions. The clinician is asked to consider and discuss relevant lay and medical evidence, to specifically include as follows: In the Veteran's November 1968 pre-separation medical examination report, no neurological abnormalities were noted In the November 1968 pre-separation medical history report, the Veteran answered in the negative to the question of whether he then had, or once had neuritis In a July 2002 VA treatment record, the Veteran reported having undergone a nerve conduction study in 1989 that revealed normal findings In a May 2006 VA treatment record, the Veteran denied experiencing numbness, tingling and radiculopathy In a November 2012 VA treatment record, the Veteran reported experiencing back pain that radiated down his left leg along with a tingling sensation. He was diagnosed with right hip and low back pain and the treating physician noted that his back pain did not radiate nor was it associated with a bladder or bowel difficulty In an October 2013 VA treatment record, a neurological review of systems revealed no tingling or numbness In a June 2017 brief, the Veteran reported experiencing pain and a burning sensation in his extremities "for many years before actually getting medical treatment." A February 2018 VA treatment record reflects that the Veteran was admitted in January 2018 for left sided weakness, hemiparesis, spastic with left upper extremity and left lower extremity paresthesias and numbness. It was noted that he underwent posterior cervical decompression and laminectomy in July 2016. Before the noted surgery, the Veteran experienced bilateral upper extremity symptoms in C7 and weakness with a gait. After the noted surgery, the Veteran's right side improved but the left side worsened. A February 2018 VA brain MRI revealed post-surgical changes, cervical spondylosis, C4-5 spinal cord atrophy and minimal gliosis The clinician is reminded that the term "at least as likely as not," does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that it is as medically sound to find in favor of the proposition as it is to find against. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Reed, Associate 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.