Citation Nr: 21072790 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 17-52 835 DATE: December 6, 2021 REMANDED Entitlement to an increased rating in excess of 20 percent for cervical spine intervertebral disc disease, myelopathy, discectomy with fusion residuals, and degenerative arthritis is remanded. Entitlement to a total rating for compensation purposes based on individual unemployability due to service connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran had active service from January 1980 to July 1981. 1. Entitlement to an increased rating in excess of 20 percent for cervical spine intervertebral disc disease, myelopathy, discectomy with fusion residuals, and degenerative arthritis is remanded. The report of a July 2020 cervical spine examination conducted for the Department of Veterans Affairs (VA) states that the Veteran exhibited a range of motion of cervical spine of forward flexion to 30 degrees, extension to 35 degrees, right lateral flexion to 25 degrees, left lateral flexion to 20 degrees, right lateral rotation to 35 degrees, and left lateral rotation to 40 degrees and pain with all ranges of motion, passive range of motion, weight bearing, and non weight bearing. The examiner indicated that the Veteran was "unable to lift more than 10 lbs.; to do repetitive movement with his neck; and to look down at his desk to write or type to due increased neck pain." The physician assistant did not identify the degree at which the identified cervical spine pain was exhibited. In light of that deficiency, the Board finds that the functional loss associated with the service connected cervical spine disability is unclear and the examination report is of limited probative value. 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). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Further VA cervical spine evaluation is needed. Clinical documentation dated after July 2020 is not of record. A 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). 2. Entitlement to a TDIU is remanded. Entitlement to a TDIU is based upon an accurate assessment of all of the service connected disabilities. The issue is therefore inextricably intertwined with the issue of an increased rating for the cervical spine being remanded and must therefore also be remanded. The matters are 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 July 2020. 3. Schedule the Veteran for a VA spine examination conducted by a medical doctor to assist in determining the current nature and severity of the service connected cervical spine disability. 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: (a) Provide ranges of motion for passive and active motion of the cervical spine for weight bearing and nonweight bearing. 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) State whether or not there is any ankylosis of the spine or any segment of the spine. (d) 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. (e) Describe any identified right or left upper extremity neurologic disabilities caused by the service-connected cervical spine disability, the nerves affected, and the level of impairment. (f) Opine as to the impact of the service connected cervical spine disability on the Veteran's vocational pursuits. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Emily A. Kotroco 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.