Citation Nr: 21072158 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 15-30 557 DATE: December 2, 2021 REMANDED Entitlement to a compensable rating prior to September 7, 2011, and a rating in excess of 10 percent from September 7, 2011, for service-connected thoracolumbar spine disability is remanded. Entitlement to service connection for a cervical spine disability, to include as secondary to service-connected thoracolumbar spine disability, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from April 1992 to February 2000. These matters were most recently before the Board in March 2021 when they were remanded for additional development. The Board notes that the Veteran's service-connected back disability was originally characterized as "lumbosacral strain, degenerative arthritis." See July 2019 rating decision - codesheet. In a June 2021 decision, the United States Court of Appeals for the Federal Circuit held that when rating a back disability, the thoracic and lumbar spine segments must be treated as a single unit for purposes of applying the General Rating Formula for Diseases and Injuries of the Spine, even if only one segment is service connected. See Langdon v. McDonough, No. 2020-1789, 2021 U.S. App. LEXIS 17115 (Fed. Cir. June 9, 2021). The Veteran is currently seeking service connection for an upper back (thoracic) disability. In light of the holding set forth in Langdon, the issue of entitlement to service connection for an upper back disability is moot, as the plain language of the regulation requires that VA treat the thoracolumbar spine as a single unit when applying the General Rating Formula. As such, the Veteran's increased rating and service connection claims have been recharacterized as shown above. 1. Rating for Thoracolumbar Spine Disability VA has a duty to ensure that any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The Board is required to reject an insufficiently detailed medical report. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). The Veteran was afforded a VA thoracolumbar spine examination in June 2021l the Board finds this examination inadequate. Specifically, the examiner noted that the range of motion of the spine was limited by pain; however, the examiner did not indicate to what extent there was additional range of motion loss (in degrees) due to pain. Additionally, the Veteran described flare-ups (doing chores made the pain 10/10 and caused headaches) but then the examiner stated the Veteran denied flare-ups and did not provide the range of motion lost during flare-ups. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011) (indicating an examination report that does not address additional range of motion loss due to factors such as pain, weakened movement, excess fatigability, incoordination, or flare-ups is inadequate for rating purposes). Therefore, on remand a new VA examination is to be conducted consistent with the directives herein. 2. Service Connection for Cervical Spine Disability This issue was remanded in March 2021 for a VA examination. Although the Veteran underwent an examination in June 2021, the Board finds the opinion to be inadequate for adjudicative purposes. Regarding direct service connection, the examiner noted a gap of 10 years between the Veteran's service discharge in 2000 and his cervical spine diagnosis. However, VA treatment records show that when the Veteran was seen in January 2003, less than three years after service, she reported a previous CT scan had revealed two herniated discs in the cervical spine. A November 2003 private treatment record also shows the Veteran was seen for complaints of neck pain. Medical examinations must be thorough and take into account the records of prior examinations and treatment. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Regarding secondary service connection, the June 2021 VA opinion is inadequate because it solely discusses medical literature without discussing the facts of the Veteran's case. See Polovick v. Shinseki, 23 Vet. App. 48, 55 (2009) (holding that a medical opinion finding no nexus based solely on medical literature is inadequate because it provides no discussion into the claimant's specific risk factors and circumstances of service). Finally, the June 2021 medical opinion never notes the specific cervical spine disability present. Therefore, remand is needed to obtain an addendum opinion. The matters are REMANDED for the following action: 1. Obtain any outstanding VA and/or private treatment records and associate them with the claims folder. 2. Schedule the Veteran for an examination with an appropriate examiner to determine the current severity of her service-connected thoracolumbar spine disability. The examiner must review pertinent documents in the Veteran's claims file in conjunction with the examination. All indicated studies should be completed, including range of motion testing. All findings must be fully reported. a) The examiner must state whether there is any evidence of favorable or unfavorable ankylosis, and determine the active and passive range of motion, in degrees, by use of a goniometer for the thoracolumbar spine. This information must be derived from testing for pain on both active and passive motion, in weight-bearing and non-weight bearing. The examination report must confirm that all such testing has been made and reflect those testing results. If any of this testing cannot be performed the examiner must note this in the report and include an explanation as to why. b) The examiner must also perform active and passive repetitive range of motion testing for the thoracolumbar spine. If pain on motion is shown, the examiner must state at what degree the pain begins. The examiner must also state whether there is weakened movement, excess fatigability, or incoordination attributable to the service-connected disability expressed in terms of the degree of additional range of motion loss or favorable or unfavorable ankylosis due to any weakened movement, excess fatigability, or incoordination. Additionally, an opinion must be stated as to whether any pain found could significantly limit functional ability during flare-ups or during periods of repeated use, noting the degree of additional range of motion loss or favorable or unfavorable ankylosis due to pain on use or during flare-ups. c) The examiner must also state whether the Veteran has intervertebral disc syndrome of the lumbar spine; if so, the examiner must state whether the Veteran experiences incapacitating episodes requiring bed rest by a physician, and the frequency and total duration of such episodes over the course of the previous 12 months. The examiner must state whether there is disc herniation with compression and/or irritation of the adjacent nerve root. d) A thorough neurologic examination of the thoracolumbar spine must be performed. The examiner must specifically state the degree of impairment present in the left and right lower extremities, which must be expressed as complete or incomplete paralysis of any nerve. The specific nerves involved must be identified. If incomplete paralysis is found, the examiner must state whether the incomplete paralysis is best characterized as mild, moderate, or severe; with the provision that wholly sensory involvement should be characterized as mild, or at most, moderate. The examiner is reminded to address the thoracic and lumbar spine segments, as it is now treated as a single unit for rating purposes. 3. Forward the Veteran's claims file to an appropriate VA examiner who must review the claims file (to include this remand) and provide an addendum opinion as to the etiology of the Veteran's cervical spine disability. The examiner should first identify all cervical spine disabilities present during the appeal period (since December 2011). In this regard, the examiner is directed to review the VA and private treatment records, as well as the VA examination reports for this period. The examiner must review the claims file and opine whether it is at least as likely as not that the Veteran's cervical spine disability: (a) had its onset in service ot is otherwise related to service; (b) was caused by service-connected thoracolumbar spine disability; or (d) is aggravated by service-connected thoracolumbar spine disability. For the purposes of secondary service connection, the examiner is advised that aggravation is defined as "any increase in disability." See Allen v. Brown, 7 Vet. App. 439, 448 (1995). If the examiner determines that the requested opinion may not be provided without a physical examination of the Veteran, then such should be scheduled. A complete rationale must be provided for all opinions presented. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should provide an explanation stating why this is so. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. K. R. FLETCHER Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Adeleke, T. 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.