Citation Nr: 21075316 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 16-04 485 DATE: December 20, 2021 REMANDED Entitlement to service connection for a cervical spine disorder is remanded. Entitlement to service connection for a right upper extremity disorder (claimed as right arm nerve damage and pain), to include as secondary to a cervical spine disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 2004 to March 2006. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in August 2018. A transcript is of record. The Board remanded the case for further development in March 2019 and June 2020. The case has since been returned to the Board for appellate review. Following the most recent remand, the AOJ obtained an additional VA medical opinion in August 2020. The examiner opined that the Veteran's cervical spine disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. He specifically stated that it was less likely than not that the disorder manifested in or is otherwise causally or etiologically related to his active service, to include any injury, symptomatology, or duties therein. In rendering the opinion, the examiner found that the service treatment records do not sufficiently demonstrate that the current cervical spine disorder was caused by or occurred during military service, as they do not show frequent physician encounters due to the claimed condition. He later noted that there were also no documented complaints of neck pain during service or proximate to his separation from service. The examiner explained that, while the rigor of military duties can result in a neck injury, there is no evidence that such an injury occurred in this case, as the records are silent for neck pain until November 2009, which would have been over three years after his separation from service. Later in the report, the August 2020 VA examiner did acknowledge that the service treatment records documented signs and symptoms that are similar to cervical radiculopathy. However, he indicated that there are other differential diagnoses that can present similar to his right upper extremity cervical radiculopathy. He explained that cervical radiculopathy can occur when there is a cervical disorder impinging on the nerve roots. Nevertheless, the examiner noted that the service treatment records show that the Veteran's C5 and C6 pack palsy was documented as improving in March 2005. He further observed that the Veteran was diagnosed with tendonitis and that he had right traps atrophy in March 2005 that was causing the pain in his lateral shoulder. Therefore, the examiner opined that the Veteran's right upper extremity symptoms in service were due to pack palsy and explained that C5 and C6 indicates the affected muscle groups rather than cervical vertebral pathology. He indicated that pack palsy occurs when there is damage to the brachial plexus (outside the cervical vertebrae/spine). In addition, the August 2020 VA examiner opined that the Veteran's current right upper extremity cervical radiculopathy is at least as likely as not caused by or aggravated by a cervical spine disorder, but less likely than not caused by his service-connected lumbar spine disability. In this regard, he explained that the lumbar spine is distant to the cervical region and does not directly cause impingement of the cervical spinal nerve roots. The August 2020 VA examiner's opinion appears to address whether a cervical spine disorder manifested in service. However, the rationale does not explain why the delayed-onset of a cervical spine disorder could not be related to pack palsy, symptomatology, or duties in service. In other words, the examiner did not explain the significance of the evidentiary gap between the Veteran's military service and later documented treatment, and he did not discuss whether the same mechanism that caused the pack palsy could have also resulted in the later development of a cervical spine disorder. Therefore, the Board finds that an additional medical opinion is needed. The Board further notes that the issue of entitlement to service connection for right upper extremity disorder is inextricably intertwined with the issue of entitlement to service connection for a cervical spine disorder. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his cervical spine and right upper extremity. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. After the foregoing development has been completed, the AOJ should request an additional medical opinion from the August 2020 VA examiner, or if he is unavailable, from another suitably qualified VA examiner, regarding the nature and etiology of the Veteran's current cervical spine disorder. A physical examination is only needed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, August 2018 hearing transcript, and lay statements. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran's current cervical spine disorder manifested in or is otherwise causally or etiologically related to his active service, to include any injury, symptomatology, or duties therein. In rendering the opinion, he or she should address the service treatment records regarding neck symptoms and the post-service medical records noting that the Veteran reported experiencing neck pain since 2005. The examiner should discuss whether the same mechanism that caused the pack palsy could have resulted in the current cervical spine disorder. He or she should also explain the significance, if any, in the delayed-onset of any current cervical spine disorder. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. The AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Kuczynski, 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.