Citation Nr: 21077203 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 18-15 026 DATE: December 28, 2021 ORDER Entitlement to service connection for chronic cervical spine myofascitis with degenerative disc disease is granted. FINDING OF FACT The Veteran's chronic cervical spine myofascitis with degenerative disc disease is shown to be causally related to an in-service cervical spine injury. CONCLUSION OF LAW The criteria for entitlement to service connection for chronic cervical spine myofascitis with degenerative disc disease have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served active duty in the United States Air Force from November 1984 to April 1988. This matter comes to the Board of Veterans' Appeals (Board) on appeal of a March 2017 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). In August 2021, the Veteran presented testimony in a videoconference hearing before the undersigned Veterans Law Judge. A copy of the transcript has been associated with the claims folder. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 1. Entitlement to service connection for cervical condition The Veteran contends he is entitled to service connection for a cervical neck condition that is related to his active-duty service. Specifically, he asserts an in-service automobile accident resulted in constant headaches, ringing in the ears, dizziness, tingling in the hands, and chronic neck and back pain since his separation from service. At his Board hearing, the Veteran testified he did not receive treatment for his condition immediately following his military service due to a lack of medical insurance, but self-treated with over the counter medication and received physical therapy. The Veteran is shown to have several diagnoses of the cervical spine, including cervical muscle strain, chronic cervical spine myofascitis with radiculopathy, and degenerative disc disease. Therefore, the first element of service connection is met. The Veteran's military personnel record confirms a motor vehicle accident occurred in December 1986 with a diagnosis of cervical spine strain. STR, 1/19/2017, pgs. 4, 8, 26/32. The evidence indicates the Veteran was a passenger in a stopped vehicle that was rear-ended at a high speed without the use of brakes. Immediately following the accident, he was given doctor's orders for bed rest, assigned a profile for limited activity, and scheduled for physical therapy. STR, 1/19/2017, pgs. 1, 3, 5, 9, 10, 17-23/24. Records show the Veteran received treatment for neck and back pain several times and a Line of Duty Report was provided in April 1987. MPR, 1/19/2017, pgs. 20-21/26. Therefore, an in-service event has been established and the second element of service connection is met. As the first and second elements of service connection have been met, the question for the Board is whether the current disability is related to his active duty. The Board concludes that the Veteran's cervical spine condition is related to his in-service automobile accident. 38 U.S.C. §§ 1110, 1131, 5107 (b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a). The evidence against the claim includes a January 2017 VA examination. The examiner diagnosed cervical strain and concluded it was less likely than not incurred in or caused by military service. The examiner relied on an absence of a separation examination and post-service treatment records showing ongoing symptoms of neck pain to conclude the Veteran's condition is not related to his active-duty automobile accident. The evidence in favor of the claim includes two medical opinions, private Disability Benefits Questionnaires (DBQ), and private treatment records. A February 2018 opinion of Dr. JR was submitted, opining the Veteran's chronic cervical pain is casually related to his active-duty motor vehicle accident. He indicated the Veteran's current symptoms were consistent with the service injury and noted an absence of evidence to the contrary. Dr. JR also provided an April 2019 letter with additional symptoms he opined are related to the motor vehicle accident and affirmed his previous finding and opinions. At his August 2021 Board hearing, the Veteran requested the record be held open to file additional medical evidence in support of a nexus relationship. An August 2021 DBQ and opinion were completed by Dr. CNB regarding his neck and headaches conditions and Dr. CNB provided testimony in support of the Veteran's claim. Dr. CNB opined the Veteran's cervical spine condition was more likely than not caused by his automobile accident, with a 90 percent probability. Dr. CNB further opined the residuals of his neck injury have been consistent with medical principles and natural history of the disease including the time lag and progression since his military separation. He explained soft tissue injuries to the spine mature into degenerative disc disease due to excessive motion of the vertebrae, noting a lack of a more plausible etiology in the record. The Board finds the medical opinions of Dr. JR and Dr. CNB highly probative and afford them significant weight. Each physician performed an in-person examination of the Veteran and provided clear conclusions with sufficient information such that the Board may make an informed decision on the matter. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). The opinions are consistent with each other and the remainder of the medical evidence and Veteran lay testimony. Further, the VA examiner improperly relied on an absence of medical records in concluding there is no relationship between the Veteran's current disability and his military injury. See Dalton v. Nicholson, 21 Vet. App. 23, 40 (2007). As such, the Board affords more probative value and weigh to the favorable medical evidence establishing a nexus relationship. Upon review of the record, the Board finds the evidence favors a finding the Veteran's cervical spine condition is related to his in-service motor vehicle accident and service connection for cervical spine disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Tabitha Chapman, 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.