Citation Nr: A21019768 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 180905-71 DATE: December 13, 2021 ORDER Entitlement to service connection for carotid sinus hypersensitivity with syncope, to include as secondary to his service-connected cervical spinal compression fracture with intervertebral disc syndrome (IVDS) is granted. Entitlement to service connection for pacemaker implantation as secondary to carotid sinus hypersensitivity with syncope is granted. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, his diagnosed carotid sinus hypersensitivity with syncope is at least as likely as not caused by his service-connected cervical spinal compression fracture with IVDS. 2. Resolving reasonable doubt in the Veteran's favor, implantation of a pacemaker is at least as likely as not caused by his carotid sinus hypersensitivity with syncope. CONCLUSIONS OF LAW 1. The criteria for service connection for carotid sinus hypersensitivity with syncope as secondary to his service-connected neck condition have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for pacemaker implantation as secondary to carotid sinus hypersensitivity with syncope have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1973 to January 1980 and January 1991 to July 1991, with additional service in the Reserves. This matter is before the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (to be codified as amended in scattered sections of 38 U.S.C.), 131 Stat. 1105 (2017), also known as the Appeals Modernization Act (AMA) was signed into law on August 23, 2017. The AMA creates a new framework for Veterans dissatisfied with VA's decision on their claim to seek review. Based on the Veteran's hearing track selection, the Board may only consider the evidence of record at the time of the June 2018 rating decision, as well as any evidence submitted at the January 2021 hearing or within 90 days after that date. 38 C.F.R. § 20.302(a). This decision is written consistent with the new AMA framework. The relevant procedural history is as follows. Separate claims for service connection for carotid sinus hypersensitivity with syncope to include as secondary to his service-connected cervical spinal compression fracture and for pacemaker implantation secondary to carotid sinus hypersensitivity with syncope were denied in a June 2015 rating decision. The Veteran filed a July 2015 Notice of Disagreement (NOD). A Statement of the Case (SOC) was issued in January 2017; both service connection claims remained denied. The Veteran filed a January 2017 VA Form 9 Formal Appeal to the Board and separately submitted new private medical treatment evidence. The RO issued a Supplemental Statement of the Case (SSOC) in March 2017; both service connection claims remained denied. The Veteran submitted a RAMP Opt-In election in June 2018. The Board is honoring the Veteran's choice to participate in VA's test program, RAMP, the Rapid Appeals Modernization Program. A June 2018 RAMP rating decision was issued with both claims denied. The Veteran filed a September 2018 VA 21-4138 RAMP selection form wherein he opted for a Board hearing. A transcript of the Veteran's January 2021 Board hearing is of record. 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). Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. To prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). VA must consider all favorable lay evidence of record. See 38 U.S.C. § 5107(b). A Veteran is competent to report on that of which he has actually observed and is within the realm of his personal knowledge. Layno v. Brown, 6 Vet. App. 465 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Service connection for carotid sinus hypersensitivity with syncope. In his October 2014 claim and at the January 2021 Board hearing, the Veteran asserted entitlement to service connection for his diagnosed carotid sinus hypersensitivity with syncope secondary to his service-connected cervical spinal compression fracture with IVDS. The May 2015 VA Artery and Vein Conditions examination report reflects a current diagnosis of carotid sinus hypersensitivity with syncope. The Veteran's service treatment records (STRs) are silent for complaints of or treatment for symptoms of carotid sinus hypersensitivity with syncope. However, STRs confirm he was involved in a 1978 motor vehicle accident wherein he sustained a neck injury. Noted treatment included a halo traction procedure. Post service treatment records include April 2014 MRI and CT imaging of the neck following the Veteran's report of chronic neck pain. A September 2015 VA spinal cord injury treatment record noted the Veteran was diagnosed with carotid sinus hypersensitivity by a private cardiologist. In addition, there are multiple psychology treatment notes in the claims file wherein the Veteran relayed the feeling of anxiety he feels during and following the syncope episodes. As noted above, the Veteran was afforded a May 2015 VA Artery and Vein Conditions examination. The examiner noted the Veteran's report that he started experiencing frequent blackouts in 2009, underwent a cardiac workup, and after monitoring, was diagnosed with carotid hypersensitivity. The Veteran also reported weekly episodes of neck pain that radiates up into the right side of his head and right medial scapular area to the right shoulder and occasional radiation down the arm. The examiner noted the Veteran had been seen by neurology. At the same time, the Veteran was also afforded a May 2015 heart conditions examination that confirmed implantation of a cardiac pacemaker from October 2014. The medical history section of the report notes that the Veteran experienced recurrent episodes of syncope starting in 2009. Placement of a cardiac pacemaker was required. The examiner noted etiology for the pacemaker was the Veteran's carotid sinus hypersensitivity with syncope associated with bradycardia, hypotension, and systole. In the attached May 2015 medical etiology opinion, the examiner opined the claimed conditions are less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. As a rationale, the examiner noted the Veteran suffered a C3/4 hemifacet dislocation during service that was treated with traction and a Halo thoracic brace fixation in 1978. The examiner indicated the Veteran has experienced recurrent episodes of syncope during the past few years, diagnosed as carotid sinus hypersensitivity syndrome. The examiner noted the recurrent episodes do not appear to be mechanically induced through neck manipulation or wearing tight collared shirts. The examiner also noted that a search of medical literature did not reveal a connection between changes of cervical spondylosis/degenerative disc disease/ radiculopathy and pain as a cause of carotid sinus hypersensitivity, and he was unaware of an old neck injury causing this syndrome. Instead, the examiner reported the etiology is unknown in most cases but occurs more often in men and in the latter decades of life. The examiner noted he cannot relate remote neck trauma, which does not involve the carotid arteries, nor the carotid sinus, nor any chronic neck pain, in the causation of his disorder. The VA examiner pointed out that the Veteran had a report from a cardiologist who postulates that a reflex pain mechanism could be the cause of his carotid sinus hypersensitivity for lack of other things to attribute to his problem. The examiner concluded by noting that unless more conclusive evidence can be brought, the claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. On the other hand, the Board notes private treatment records establish a long history of syncopal episodes and treatment. The claims file includes August 2014 private emergency department treatment records that noted the Veteran experienced an episode of syncope, hit his head, and lacerated his scalp in two areas. Separate discharge instructions indicate severe pain is a potential syncope trigger. A September 2014 treatment letter from the Veteran's private cardiologist noted the Veteran underwent a tilt table test that revealed carotid sinus hypersensitivity and showed he was asystole ("flatlined") for approximately six seconds during the test. Based on these results, the cardiologist recommended the Veteran have a pacemaker inserted. October 2014 private treatment records noted placement of a pacemaker and post-surgical follow-up. In a separate October 2014 treatment record, the Veteran's private cardiologist indicated that there might be a link between pain and the prior syncopal episodes experienced by the Veteran. The Board carefully reviewed the January 2017 private treatment record noted above. In this record, the private cardiologist noted the Veteran's pacemaker appears to be functioning well and has successfully prevented syncopal episodes despite continued occasional pain crisis. The cardiologist noted a review of VA treatment records including operative reports, follow-up records and an MRI. The cardiologist noted those records document a cervical spine injury which in his opinion absolutely explains the recurrent pain crisis that resulted in prior syncopal episodes. In his January 2021 hearing, the Veteran reported a motor vehicle accident in 1978 wherein he sustained a neck injury, that symptoms of his carotid sinus hypersensitivity were first noticed in 2009 when he felt sick during a car ride and fainted on the roadside when he stepped out to get some air, and then outlined his subsequent diagnosis and treatment. The Board finds the Veteran's statements to be competent and credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Based on the above, the Board finds that the evidence of record is at least in equipoise as to whether the Veteran's carotid sinus hypersensitivity with syncope is caused by pain from his service-connected neck condition. The Board is mindful of the negative May 2015 medical opinion; however, this opinion only serves to place the medical evidence in a state of relative equipoise with the medical opinion from the Veteran's private cardiologist expressed in the January 2017 treatment record. Resolving all doubt in the Veteran's favor, the Board finds the record is in relative equipoise when the required elements of a claim for secondary service connection based are considered. The mandate to accord the benefit of the doubt is triggered when the evidence has reached a stage of equipoise. In this case, as there a diagnosis of carotid sinus hypersensitivity with syncope, and competent and credible statements from the Veteran's treating cardiologist in favor of the claim, the Board believes equipoise has been attained. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). As such, after resolving all reasonable doubt in the Veteran's favor, service connection for carotid sinus hypersensitivity with syncope secondary to his service-connected neck condition is warranted. Thus, the claim for service connection is granted. 2. Service connection for pacemaker implantation secondary to carotid sinus hypersensitivity with syncope. In his October 2014 claim Veteran also asserts entitlement to service connection for implantation of a pacemaker secondary to his now service-connected carotid sinus hypersensitivity. As noted above, the Veteran was afforded a May 2015 VA heart conditions examination. Placement of a pacemaker was confirmed; the attached medical opinion does not specifically address the pacemaker. However, the September 2014 treatment letter from the Veteran's cardiologist indicated a recommended pacemaker after the September 2014 tilt table test revealed carotid sinus hypersensitivity and showed he was asystole (flatline) for approximately six seconds. There are no other medical opinions regarding etiology for the pacemaker in the Veteran's claims file. In his January 2021 hearing, the Veteran reported he was initially reluctant to have the pacemaker implanted but subsequent syncopal events have occurred without him passing out. The Board finds the Veteran's statements to be competent and credible. Jandreau, supra. Based upon the above noted evidence and resolving all reasonable doubt in the Veteran's favor, the Board finds there is sufficient evidence of record establishing that his pacemaker was implanted secondary to his carotid sinus hypersensitivity, for which service connection is granted elsewhere in this decision. Accordingly, the Board finds that service connection for implantation of a pacemaker is warranted. J. Kirby Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Banks, 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.