Citation Nr: 21074429 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 17-50 220 DATE: December 15, 2021 ORDER The petition to reopen a previously denied claim for service connection for sleep apnea is denied. Entitlement to service connection for a lung nodule is denied. Entitlement to service connection for a bilateral hearing loss is granted. REMANDED Entitlement to service connection for a left arm tremor as a residual of left hand burn is remanded. Entitlement to service connection for symptoms of intermittent numbness and tingling of fingertips as residuals of the left hand burn is remanded. Entitlement to service connection for right eye nerve damage is remanded. Entitlement to service connection for a back disorder claimed as spinal cord degeneration is remanded. FINDINGS OF FACT 1. Claims for service connection for sleep apnea were denied by the agency of original jurisdiction (AOJ) in November 2015 and August 2016; the Veteran did not perfect an appeal or submit new and material evidence within one year of the determinations, and evidence obtained since then does not raise a reasonable possibility of substantiating the underlying service connection claim. 2. The Veteran is not shown to have current disability manifested by a lung nodule. 3. There is an approximate balance of positive and negative evidence as to whether the Veteran's hearing loss is related to conceded acoustic trauma during his military service. CONCLUSIONS OF LAW 1. New and material evidence has not been received and the claim for service connection for sleep apnea is not reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156(a), 20.1103. 2. The criteria for service connection for a lung nodule are not met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107(b); 38 C.F.R. § 3.303. 3. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for hearing loss are met. 38 U.S.C. §§ 1110, 1112, 1113, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1982 to July 1985. In June 2021, he testified at a virtual hearing held before the Board of Veterans' Appeals (Board). A transcript of the hearing is of record. New and Material Evidence The Veteran seeks to reopen a previously denied claim for service connection for sleep apnea. Generally, a claim denied in an unappealed rating decision or an unappealed Board decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). The exception is that, if new and material evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. New evidence means evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the credibility of the new evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513(1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. When evaluating the materiality of newly submitted evidence, the focus must not be solely on whether the evidence remedies the principal reason for denial in the last prior decision; rather the determination of materiality should focus on whether the evidence, taken together, could at least trigger the duty to assist or consideration of a new theory of entitlement. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). The Board has jurisdictional responsibility to determine on its own whether there is new and material evidence to reopen properly a service-connection claim. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (citing 38 U.S.C. §§ 5108, 7105(c)); Barnett v. Brown, 83 F. 3d 1380 (Fed. Cir. 1996). The submission of "new and material" evidence is a jurisdictional prerequisite to the Board's review on the merits of a previously denied claim. In November 2015, the AOJ originally denied service connection for sleep apnea on the basis that the condition was not incurred in or caused by service. This rating decision became final as the Veteran did not perfect an appeal or submit new and material evidence within one year of the determination. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.156 (b), 20.1103; see also Bond v. Shinseki, 659 F.3d 1362 Fed. Cir. 2011); Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). In an August 2016, rating decision, the RO continued the denial of service connection for sleep apnea, on the basis that the evidence submitted was not new and material as it failed to support a nexus between the current diagnosis and the Veteran's service. This rating decision also became final as no notice of disagreement or new and material evidence was submitted within one year of the dates on which it was issued. Id. The August 2016 rating action is the last final denial as to this issue on any basis before the present attempt to reopen the claim. The relevant evidence of record in August 2016 includes service treatment records which are negative for complaints or findings suggestive of sleep apnea. Post-service records show obstructive sleep apnea was first diagnosed during a sleep study in April 2015; however, no medical professional or medical evidence suggests a relationship between the claimed disorder and the Veteran's service. The record also documents the Veteran's assertion that his sleep apnea is due to military service. Evidence added to the record since then includes medical evidence that documents continued treatment for sleep apnea but does not otherwise offer any probative evidence of a nexus to service. See Cornele v. Brown, 6 Vet. App. 59, 62 (1993). See also Morton v. Principi, 3 Vet. App. 508 (1992) (per curiam) (medical records describing Veteran's current condition are not material to issue of service connection and are insufficient to reopen claim for service connection based on new and material evidence). In other words, there is no probative evidence, such as a medical opinion linking his sleep apnea with service. Shade, 24 Vet. App. at 117. Additional evidence also includes the Veteran's continued assertions made during his June 2021 Board hearing that his sleep apnea was incurred in service. In this case, the lay evidence goes to the same arguments that were previously made and addressed by the AOJ in August 2016, and thus is not considered new" within the meaning of 38 C.F.R. § 3.156(a). See Reid v. Derwinski, 2 Vet. App. 312, 315 (1992); see also Moray v. Brown, 5 Vet. App. 211, 214 (1993). Because new and material evidence has not been received, the Veteran's claim is not reopened, and entitlement to service connection for sleep apnea remains denied. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Service Connection The Veteran is seeking service connection for a lung nodule and hearing loss. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (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 - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Certain chronic diseases are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). Continuity of symptomatology may also provide a basis for a grant of service connection for those diseases defined as "chronic" by VA. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015). Service connection may be granted for any disease initially 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, any reasonable doubt is resolved in favor of the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. lung nodule At his June 2021 Board hearing the Veteran testified that he developed a pulmonary disorder described as a lung nodule/lung scarring secondary to his exposure to jet exhaust, chemicals, fuel, and heat from the jet blasts during service. See hearing transcript (Tr.) pages 11, 13, 14, and 19; see also VA treatment records from Lafayette Community Based Outpatient Clinic (CBOC). However, the primary impediment to a grant of service connection is the absence of a currently diagnosed disorder. Service treatment records are entirely negative for pulmonary complaints. At his separation physical in June 1985, clinical evaluation of the chest and lungs as well as a chest X-ray was normal. Likewise, VA and private treatment records from 1999 to 2020 have been associated with the claims file and show no specific clinical findings or confirmed diagnoses of an actual lung nodule documented in "active problem lists" or in any report of past medical history. See clinical records from Lafayette Community Based Outpatient Clinic (CBOC), from Alexandria VA Medical Center (VAMC) and from West Palm Beach VAMC. These records do show that in May 2016, the Veteran sought evaluation for dyspnea and the sensation of burning type pain in the lungs on exertion. He was concerned that exposure to jet exhaust fumes and asbestos while serving on an aircraft carrier caused chronic obstructive pulmonary disease (COPD) and pneumoconioses/scarring of his lungs. See clinical records from Lafayette CBOC dated August 7, 2015. Although pulmonary function testing from January 2015 suggested underling restrictive impairment, the respiratory therapist at that time indicated the Veteran may not have given maximum effort and a CT scan showed no appreciable structural pulmonary changes. It was also noted that the Veteran had a recent biopsy of a thyroid nodule. See Pulmonary Progress Note from Alexandria VAMC dated January 27, 2015. Since service and post-service treatment records provide no basis to grant this claim, and in fact provide evidence against it, the Board finds no basis for VA to provide an examination. Duenas v. Principi, 18 Vet. App. 512, 519 (2004) (holding that VA is not obligated to provide an examination for a medical nexus opinion where, as here, the supporting evidence of record consists only of a lay statement). At this point the Veteran has not provided any meaningful description of a current disorder manifested by a lung nodule, to trigger a VA examination through evidence of symptoms of a potential disability. Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; Hunt v. Derwinski, 1 Vet. App. 292 (1991); Allen v. Brown, 7 Vet. App. 439 (1995); Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (the term "disability" as used in 38 U.S.C. § 1110 refers to the functional impairment of earning capacity). The objective evidence does not show a diagnosis of a lung nodule or other pulmonary disorder at the time of the filing of the claim or during the pendency of the claim. In addition, the Veteran has not described or presented evidence of any specific functional loss or impairment due to a lung nodule or other pulmonary disorder. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F.3d 1328 (1997) (holding that the VA's and the Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board finds that the weight of the evidence reflects that the Veteran does not currently have a current disorder manifested by a lung nodule to include a showing of chronic pulmonary functional impairment. So, without competent evidence of a current disability, service connection cannot be awarded for lung nodule. Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). hearing loss The Veteran asserts that his hearing loss is the result of noise exposure during service. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The threshold for normal hearing is from zero to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Id.; Hensley v. Brown, 5 Vet. App. 155, 157 (1993); McKinney v. McDonald, 28 Vet. App. 15, 24-5 (2016). The absence of in-service evidence of a hearing disability during service (i.e., one meeting the requirements of 38 C.F.R. § 3.385) is not always fatal to a service connection claim. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing loss disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for a hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service (as opposed to intercurrent causes). See Hensley, 5 Vet. App. at 159. The Veteran's DD-214 shows that he served as a maintenance tech, a military occupational specialty (MOS) typically associated with routine exposure to hazardous noise levels. 38 U.S.C. § 1154(a). Also, the AOJ has already conceded the Veteran's in-service noise exposure in its June 2015 grant of service connection for tinnitus based on such exposure. A May 2015 VA audiogram confirms the Veteran has hearing loss disability for VA purposes. After carefully reviewing and weighing the competent medical evidence of record, the Board is satisfied that it is in at least approximate balance as to whether the Veteran's current hearing loss is related to service. The unfavorable evidence consists of service treatment records, which are entirely negative for hearing complaints, as well as the many years after that period of service during which he did not seek or require any form of treatment or evaluation for pertinent complaints. In addition, a VA audiologist noted the Veteran's in-service noise exposure, but concluded that hearing loss did not result from it. The audiologist explained that the Veteran's hearing thresholds at time of entrance and separation were within normal limits. They also cited to a finding from the American College of Occupational Medicine Noise and Hearing Conservation Committee, that "a noise induced hearing loss will not progress once it is stopped." See May 2015 LHI VA Compensation & Pension Exams Hearing Loss and Tinnitus Disability Benefits Questionnaire (DBQ). However, the record also contains favorable evidence primarily the Veteran's likely exposure to some degree of acoustic trauma during service as is confirmed by his military duties. The Board also finds the Veteran's testimony of impaired hearing since service is both competent and credible, and thus is additional positive evidence that supports a finding of nexus. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). This supporting evidence places the pertinent record in relative equipoise. Also, because the Veteran has already been granted compensation for tinnitus, this fact adds weight to this claim that his hearing loss is also related to service. Finally, although the Board cannot ignore or disregard the negative medical conclusions, see Willis v. Derwinski, 1 Vet. App. 66 (1991), we are free to assess evidence and are not compelled to accept a medical opinion. See Wilson v. Derwinski, 2 Vet. App. 614 (1992). In this case, the VA opinion is problematic in that the audiologist seemed to rely primarily on the Veteran having normal hearing acuity during service and at discharge. However, as noted above, the absence of hearing loss at discharge from service is not a bar to service connection. See Ledford, 3 Vet. App at 89. Because the VA opinion does not sufficiently assist the Board in resolving this claim, it cannot serve as the basis of a denial of service connection. In this case, any doubt that remains is resolved in the Veteran's favor and service connection for hearing loss is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND residuals of the left hand burn, to include left arm tremor The Veteran is seeking service connection for residuals of burn to the left hand to include left arm tremors which he asserts had its onset during his military service. At his June 2021 Board hearing, he testified that he sustained a burn injury to his left hand during service and since then has developed nerve damage, described as weakness, twitching, and tremors. He testified that he has trouble closing his hand or grasping items. Service treatment records confirm the Veteran was treated for a second degree burn to the left hand in August 1984. The wound was superficial and covered almost 50 percent of the palm and the palmar aspect of the thumb causing some trouble with opposition and abduction. The wound was later debrided and healed with no sign of infection. During VA examinations in December 2017, the examiner found the Veteran did not have a current diagnosis associated with left hand burn injury. Physical examination of the left hand, including strength and range of motion, was normal and that the Veteran did not have any left hand scars, contractures, or disfigurement. The examiner concluded the history of superficial second degree burn of the palm of the left hand had healed with no evidence of disease. However, the examiner also noted the Veteran's reported symptoms of intermittent numbness and tingling of fingertips of the left hand and indicated their relationship to the healed superficial second degree thermal burn of left palm and proximal thumb was uncertain. See Hand and Finger Conditions Disability Benefits Questionnaire (DBQ) and Scars/Disfigurement DBQ. Since that examination, the Veteran underwent electrodiagnostic (EMG/NCS) testing which showed evidence of mild left cubital tunnel syndrome. Because this new evidence was not available at the time of the VA examination, remand for a new examination is necessary to determine whether the left cubital tunnel syndrome is a residual of the in-service burn injury. right eye nerve damage/vision loss At his June 2021 Board hearing, the Veteran testified that he sustained an injury to his right eye during service and since then has developed right eye muscle weakness and twitching. He also testified that he has vision loss secondary to exposure to chemicals and heat from jet blasts. Service treatment records confirm the Veteran was treated for a superficial laceration to the right cheekbone area near the lower eyelid while playing racquetball in December 1983. Post service treatment records show the Veteran has been evaluated for complaints of decreased vision, light flashes, twitching and history of pre-stage glaucoma. Following examination, the clinical assessment was cupping-asymmetric, open angle with borderline findings, and presbyopia. See clinical records from The Eye Clinic, dated August 19, 2014. VA treatment records show that in July 2016 the Veteran complained of blurred vision and an ongoing issue with eye twitching over the last three years. See VA Ophthalmology Technician Note, dated July 8, 2016. In this case the Veteran has provided evidence of both an incident in service along with complaints of continued problems since then, which requires further explanation or development. He has not been afforded a VA examination regarding his claimed right eye disorder and VA has a duty to assist him in substantiating his claim by obtaining a competent medical opinion addressing the etiology and onset of his claimed disability. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). spinal cord degeneration At his June 2021 Board hearing, the Veteran testified that he developed a spinal disorder as a result of his military duties as a "plane captain" which involved performing pre- and post-flight inspections and required him to carry 125 pounds of chain in order to tie the plane down to the deck of the aircraft carrier. The record also shows the Veteran was involved in multiple car accidents after service with several documented accidents between 2014 and 2020. The post-service records include radiological findings from February 2015, which show multilevel foraminal narrowing that is severe at some levels and mild to moderate spinal stenosis. The lumbar spine findings show marked narrowing of L5-S1 disc. See Physical Therapy Outpatient Progress Note dated June 15, 2015. These records also show the Veteran had been in numerous motor vehicle accidents one of which resulted in a neck injury with herniated C4-5 disc. Although on one occasion he asked the examiner to indicate that his spine problems originated from his heavy lifting in the Navy, only his multiple car accidents were mentioned. See VA Ambulatory/Outpatient Care Note dated July 3, 2014 and May 11, 2015. In support of his claim the Veteran submitted an opinion from his private chiropractor who concluded that the Veteran's spinal degenerative was most likely caused by or a result of service. He explained that because some disc degenerations are older, he suspected they would be the result of or at time of military service. See Nexus Statement from K. Brien, D.C. dated August 8, 2017. In October 2018 the Veteran submitted a second medical opinion from a private chiropractor who noted that a recent MRI of the lumbar spine showed multilevel intervertebral disc herniation and bony spinal degeneration and a CT scan of the cervical spine showed degenerative changes. Noting the Veteran's reported history of years of carrying and handling heavy equipment while in the Navy, the chiropractor found that such arthritis changes would point to distant rather than recent history. See Medical Statement from J. Findlay, D.C. dated October 4, 2018. Unfortunately, both opinions are inadequate as neither medical provider referenced any clinical data or other evidence to support their conclusions. See Sklar v. Brown, 5 Vet. App. 140 (1993) (the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) (the failure of a physician to provide a basis for his or her opinion affects the weight or credibility of the evidence); Bloom v. West, 12 Vet. App. 1985 (1999) (holding that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion."). The Veteran has not been afforded a VA examination regarding his claimed spinal degeneration disorder and VA has a duty to assist him in substantiating his claim by obtaining a competent medical opinion addressing the etiology and onset of his claimed disabilities. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon supra. By this remand, the Board makes no determination, express or implied, as to the credibility of any statements on file. The matters are REMANDED for the following action: 1. Obtain all clinical records, both VA and non-VA, pertaining to any treatment of the Veteran for any left hand symptoms, right eye problems, and spinal problems, that are not already in the claims file. 2. Schedule the Veteran for appropriate VA examination to determine the etiology of the Veteran's left cubital tunnel syndrome. The examiner should elicit a detailed history regarding the onset and progression of relevant symptoms, and the examination report should include a discussion of the Veteran's documented medical history. Any appropriate evaluations, studies, and testing should be conducted, and the results included in the examination report. a) The examiner should identify the likely cause(s) for the Veteran's complaints of tremors, weakness, twitching, numbness and tingling of the fingertips of the left hand, including whether they are at least as likely as not (a probability of 50 percent or greater) symptoms/manifestations of his recently diagnosed left cubital tunnel syndrome. b) If so, the examiner should then state whether it is at least as likely as not, (i.e., a 50 percent probability or greater), that the left cubital tunnel syndrome is related to the documented in-service left hand burn injury from August 1984. In providing this opinion, the examiner should carefully consider the objective medical findings in the service treatment records and discuss the likelihood of the Veteran's documented in-service left hand burn injury as the possible onset of, or precursor to, left cubital tunnel syndrome. If left cubital tunnel syndrome cannot be regarded as having had its onset during active service, the examiner should explain the Veteran's complaints of left hand tremors, weakness, twitching, and numbness and tingling of the fingertips. The examiner should provide a clear rationale for the opinion offered, including discussion of the facts of this case and any medical studies or references relied upon. If he or she is unable to provide an opinion without resorting to speculation, they must provide a reasoned explanation for such conclusion. 3. Schedule the Veteran for appropriate VA examination to determine the etiology of the Veteran's claimed right eye disorder. The examiner should elicit a detailed history regarding the onset and progression of relevant symptoms, and the examination report should include a discussion of the Veteran's documented medical history. Any appropriate evaluations, studies, and testing should be conducted, and the results included in the examination report. The examiner should identify all current right eye/vision conditions the Veteran experiences and state whether it is at least as likely as not (a probability of 50 percent or greater) that any diagnosed condition is a residual of his documented in-service right eye laceration injury in December 1983 or is otherwise related to exposure to chemicals and heat from jet exhaust as a result of his military duties. In providing this opinion the examiner should discuss: a) the objective medical findings in the service treatment records, which document the 1983 right eye laceration injury and b) the theory that the Veteran's exposure to chemicals, fuel, heat and jet exhaust as a "plane captain" caused or contributed to any currently diagnosed right eye condition/vision problems. The examiner should provide a clear rationale for the opinion offered, including discussion of the facts of this case and any medical studies or references relied upon. If he or she is unable to provide an opinion without resorting to speculation, they must provide a reasoned explanation for such conclusion. 4. Schedule the Veteran for appropriate VA examination to determine the etiology of the Veteran's claimed spinal degeneration. The examiner should elicit a detailed history regarding the onset and progression of relevant symptoms, and the examination report should include a discussion of the Veteran's documented medical history. Any appropriate evaluations, studies, and testing should be conducted, and the results included in the examination report. After review of the record the examiner should identify all current spinal disorders and state whether it is at least as likely as not, (a 50 percent probability, or greater) that such disorder is related to the performance of his military duties as opposed to his post-service history of multiple car accidents. The examiner is advised that a lack of documentation of treatment in the service records or a lack of formal diagnosis of back disorder during service cannot be the only basis by which to reject a possible nexus to service. In providing this opinion the examiner should discuss: a) the objective medical findings in the service treatment records; b) the theory that the Veteran's heavy lifting associated with his military duties as a "plane captain" caused or contributed to his spinal problems; and c) the Veteran's multiple post-service motor vehicle accidents. The examiner should provide a clear rationale for the opinion offered, including discussion of the facts of this case and any medical studies or references relied upon. If he or she is unable to provide an opinion without resorting to speculation, they must provide a reasoned explanation for such conclusion. Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.R. Bryant 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.