Citation Nr: 21009699 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 14-15 847A DATE: February 23, 2021 REMANDED Service connection for a headache disability is remanded. Service connection for a lumbar spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1990 to December 1990 and from December 1990 to July 1991. This matter originally came before the Board of Veterans’ Appeals (Board) from a June 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. The Veteran testified at a February 2017 Board video-conference hearing before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript is associated with the claims file. This matter has previously been remanded by the Board for further development, most recently in August 2020. This matter is again before the Board and has been advanced on the docket pursuant to 38 C.F.R. § 20.902(c). Service connection for a headache disability and service connection for a lumbar spine disability are remanded. The Veteran believes that service connection for a headache disability and service connection for a lumbar spine disability are warranted. See Hearing Transcript. Medical opinions for both issues were completed in September 2020. See September 2020 C&P Exam; November 2020 C&P Exam. The Board finds all the September 2020 medical opinions inadequate for multiple reasons. First, the medical opinions did not substantially comply with the Board’s remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998). Specifically, they did not consider the Veteran’s lay statements of in-service incurrence and continuity of symptomatology. Second, the medical opinions did not consider/were not able to consider all the relevant evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Specifically, the rest of the Veteran’s lay statements were not considered. Third, the medical opinions were based on inaccurate facts. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Specifically, the period of active duty service being considered was from December 1990 to July 1991. However, the Veteran also served on active duty from August 1990 to December 1990. The headache medical opinion also stated that the first headache of record was in 2014, while records show headaches long before that. See January 2018 Medical Treatment Record. Therefore, a remand is needed for new VA medical opinions. Additionally, the record suggests that the Veteran served in the Army Reserve. See DD-214; January 2014 Military Personnel Records. However, it does not appear that all the Veteran’s Reserve records have been obtained. Therefore, a remand is also needed to obtain these records. The matter is REMANDED for the following action: 1. Update VA and private treatment records. VA treatment records appear current up to September 2019. 2. Contact all appropriate sources to obtain the Veteran’s Army National Guard/Army Reserve service treatment and personnel records. All efforts to obtain these records should be documented, and if the records cannot be located, a formal finding of unavailability should be associated with the Veteran’s claims file. The record suggests that the Veteran had Reserve service before and after his active duty service. 3. Make a formal finding for all periods of active service, ACDUTRA, and/or INACDUTRA in terms of specific dates. If this cannot be accomplished, provide an explanation. 4. Schedule one or more appropriate VA medical opinions for the Veteran’s headache and lumbar spine disabilities. Following a review of the claims file and a copy of this Remand, the reviewing medical professional is requested to furnish an opinion with respect to the following: (A) Identify all headache and lumbar spine related disabilities existing at any point during the pendency of the appeal (i.e. since October 2010), even if they are currently asymptomatic or have resolved during the pendency of the appeal. (B) For each identified disability, is it at least as likely as not (a 50 percent or greater probability) that the disability is related to the Veteran’s active duty service, active duty for training (ACDUTRA), and/or inactive duty for training (INACDUTRA)? If so, for which periods? (C) For each identified disability, is it at least as likely as not (a 50 percent or greater probability) that the disability is/was caused by any or all of the Veteran’s service-connected disabilities (including any medications taken for the service-connected disabilities)? (D) For each identified disability, is it at least as likely as not (a 50 percent or greater probability) that the disability is/was aggravated beyond its natural progression by any or all of the Veteran’s service-connected disabilities (including any medications taken for the service-connected disabilities)? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. (E) Is it at least as likely as not (a 50 percent or greater probability) that any or all of the Veteran’s service-connected disabilities (including any medications taken for the service-connected disabilities) caused or aggravated the Veteran’s obesity/being overweight including whether there is/was any incremental increase in disability or aggravation as a result of service? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. (F) If yes, is it at least as likely as not (a 50 percent or greater probability) that the obesity/being overweight caused or aggravated any or all of the Veteran’s headache and/or lumbar spine related disabilities including whether there is/was any incremental increase in disability or aggravation as a result of service? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. If yes, which ones? (G) Is it at least as likely as not (a 50 percent or greater probability) that any headaches and/or any lumbar spine arthritis manifested to a compensable degree within one year after the Veteran’s separation from a period of active duty service? If yes, which ones? Any lumbar spine disability determined to be service connected should be considered as one of the Veteran’s service-connected disabilities for purposes of the above questions. In providing an opinion, the reviewing medical professional should consider all the evidence listed further below in this Remand. A complete rationale for all opinions offered should be provided. Address the Veteran’s documented history and assertions. All necessary tests and studies should be conducted. If the reviewing medical professional cannot provide an opinion without resorting to mere speculation, the reviewing medical professional should provide an explanation stating why. In so doing, the reviewing medical professional should explain whether the inability to provide a more definitive opinion is due to the limits of the medical community’s knowledge or the limits of the reviewing medical professional’s medical knowledge. The Veteran is competent to attest to factual matters of which the Veteran has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the reviewing medical professional should provide a fully reasoned explanation. 5. Schedule one or more appropriate VA Gulf War medical opinions for the Veteran’s headache and lumbar spine related disabilities. Following a review of the claims file and a copy of this Remand, the reviewing medical professional is requested to furnish an opinion with respect to the following: (A) Determine whether the Veteran’s headache and lumbar spine symptoms are attributable to a known clinical diagnosis or a chronic multi-symptom illness of partially understood etiology and pathophysiology. (B) For any symptoms that are attributable to a known clinical diagnosis or a chronic multi-symptom illness of partially understood etiology and pathophysiology, is it at least as likely as not (a 50 percent or greater probability) that the disability is related to the Veteran’s service, to include conceded environmental hazard exposure in Southwest Asia? (C) For any symptoms that are not attributable to a known clinical diagnosis or a chronic multi-symptom illness of partially understood etiology and pathophysiology, does the Veteran have objective indications, as established by history, physical examination, and laboratory tests, of an undiagnosed illness or a medically unexplained chronic multi-symptom illness, manifested by identified symptoms that have existed for six months or more or exhibited intermittent episodes of improvement and worsening over a six-month period? A “medically unexplained chronic multi-symptom illness” is defined as a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. In providing an opinion, the reviewing medical professional should consider all the evidence listed further below in this Remand. A complete rationale for all opinions offered should be provided. Address the Veteran’s documented history and assertions. All necessary tests and studies should be conducted. If the reviewing medical professional cannot provide an opinion without resorting to mere speculation, the reviewing medical professional should provide an explanation stating why. In so doing, the reviewing medical professional should explain whether the inability to provide a more definitive opinion is due to the limits of the medical community’s knowledge or the limits of the reviewing medical professional’s medical knowledge. The Veteran is competent to attest to factual matters of which the Veteran has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the reviewing medical professional should provide a fully reasoned explanation. 6. For any and all VA medical opinions, in addition to the other relevant evidence of record, the reviewing medical professionals are asked to consider the following information with a caution that this list is not a substitute for a review of the record: Headaches (1) A list of the Veteran’s service-connected disabilities. See January 2019 Rating Decision – Codesheet. (2) A 2020 medical record showing that alcohol is famous for causing hangover headaches. See November 2020 C&P Exam. (3) A 2020 medical record showing that the current level of headache severity was greater than the baseline was. See September 2020 C&P Exam. (4) 2019 medical records showing the Veteran’s endorsement of alcohol withdrawal symptoms, which included headaches. There was a withdrawal history of headaches. There was a body mass index of 29.4. See August 2020 CAPRI. (5) 2018 medical records showing a body mass index of 32.1. See April 2019 CAPRI. (6) 1995 medical records showing complaints of headaches in the facial area with a one-month history. The Veteran had painful headaches and he complained of pounding headaches felt mostly towards the facial area. Headaches were on the problem list. The Veteran appeared to get headaches when he had pharyngitis/sinusitis. See January 2018 Medical Treatment Record. (7) 2016 medical records showing that low back pain required medication, which the Veteran believed may have been causing headaches. See February 2017 CAPRI. (8) 2004 medical records showing that the Veteran may have gotten headaches from paroxetine, an antidepressant. Id. (9) The Veteran’s report of no headache problems prior to service. The headaches started during active duty in Saudi Arabia with the dust, environment, blowing winds, big sandstorms, and burning oil fields. He constantly breathed the air and saw a black sky from the oil burning. At one point, he was surrounded by oil fields. Headaches/migraines occurred. He felt constant congestion and went to sick bay where he was given allergy medicine and medicine for the headaches. He was young and tough and didn’t want to be in sick bay much. He did not get treatment for headaches when he first left service. He assumed that they were stress headaches and were related to his alcohol addiction. He had PTSD and was in denial, so he did not get help. Breathing issues and severe allergies were noted in his service records. He was diagnosed with migraines while he was incarcerated. He had consistent headaches during service and ever since. See Hearing Transcript. (10) Service records showing a clean entrance examination, a headache in October 1990, some headaches in April 1991, and frequent or severe headaches and a lot of headaches in June 1991. The Veteran had the stomach flu while in Southwest Asia. See January 2014 STR – Medical. (11) 2011 medical records showing that the Veteran recently fell and hurt the back of his head, requiring staples. The Veteran did not want to talk about how much he had had to drink. The fall appeared to be alcohol related. See June 2012 CAPRI. (12) 2010 medical records showing that the Veteran took buspirone and hydroxyzine for his service-connected PTSD with alcohol dependence. The side effect was headaches. The Veteran had head pain for years. The Veteran had tension headaches which were a diagnosable but partially explained illness. 2009 medical records showed that the Veteran was intoxicated, fell, and hurt the back of his head. The Veteran had a diagnosis of headaches. Id. (13) A 2010 medical record showing that the Veteran had several traumatic injuries to the head associated with alcohol intoxication in the last several years, which may have contributed to his current headaches. See December 2010 VA Examination. (14) 2007 medical records showing that the Veteran had seizures due to alcohol dependence/withdrawal. See December 2017 CAPRI. 2008 medical records showed a large hematoma to the back of the head from what the Veteran reported to be a seizure. See June 2012 CAPRI. (15) All other relevant lay and medical evidence.   Lumbar Spine (16) 2018 medical records showing the Veteran’s report of doing a lot of running and pushups during active service. There was a body mass index of 32.1. See April 2019 CAPRI. (17) 1995 medical records showing back pain from lifting a heavy object. There was a prior history of back spasms eight months prior. There was a diagnosis of lower back strain. 1994 medical records showed lower back pain, which was muscular in type. There appeared to be possible symptoms for disc problems. 1993 medical records showed back pain. The Veteran had injured his left knee on active duty. See January 2018 Medical Treatment Record. (18) 2016 medical records showing low back pain for 20 years. See February 2017 CAPRI. (19) The Veteran’s report of no lumbar spine problems before service. During service, he lifted remains and put them on pallets. He did a lot of lifting in that capacity. He removed body bags from choppers, took them to the mortuary, unloaded them, identified remains, loaded them into a coffin, iced them up, and then loaded them back onto a pallet. His low back problems were caused by the large amount of constant heavy lifting and carrying. He went to sick bay a couple of times and was given ibuprofen and muscle relaxers. He was so busy during wartime, that he was discouraged from going to sick bay often. No full work up of the back was done during service. Around age 27, his back had serious issues and he got x-rays which showed a diagnosis of chronic back pain with degenerative issues. The first back MRI was done in 2016. A doctor told him that he should have been given an MRI years ago because of the 20 years of back problems. One time during service, there was a scud-like attack. He was on a flatbed wearing his 40-pound rucksack with his M-16 with him. He had a tumble where he fell off the truck and hurt his knee. He hurt his back during that incident as well. He felt a pain shoot up through his lower back and knew that he needed a muscle relaxer or something to help with the pain because it progressed. He spent seven and a half months loading and unloading remains, which made it hard for his back to recover. Usually, two people lifted one body bag, but during emergencies like scud missile attacks, one person dragged one body bag away from the helipad. Since service, the Veteran never had any traumatic injury to the back. It chronically got worse. He first went to the doctor at 27 because it was finally bad enough that he needed to get it checked out. See Hearing Transcript. (20) Service records showing an injury to the left knee. See January 2014 STR – Medical. (21) 2011 medical records showing that the Veteran drank and had back pain. See June 2012 CAPRI. (22) 2010 medical records showing back pain for years. The Veteran reported back pain on the lower left side and continued to consume alcohol. See June 2012 CAPRI. (23) A 2010 medical record showing longstanding lumbar spine degeneration. See December 2010 VA Examination. (24) 2010 medical records showing severe arthritis of the spine and liver alcohol disease. There was lower back pain centered around the left kidney area. See November 2010 Medical Treatment Record. (25) All other relevant lay and medical evidence. 7. Readjudicate the issues on appeal. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Dougan, 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.