Citation Nr: 21010117 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 13-33 492 DATE: February 24, 2021 REMANDED Entitlement to service connection for a cervical spine disability, to include cervical strain (claimed as neck pain), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from May 1992 to April 1998. His decorations include the Army Achievement Medal, the Army Good Conduct Medal, and the National Defense Service Medal. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office in Decatur, Georgia. The issue on appeal was previously before the Board in June 2015 and May 2020, when it was remanded to the agency of original jurisdiction (AOJ) for additional development. On both occasions, after taking further action, the AOJ confirmed and continued the prior denial and returned the case to the Board. Entitlement to service connection for a cervical spine disability is remanded. Although the Board sincerely regrets the additional delay, another remand is necessary to ensure substantial compliance with the Board’s May 2020 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). When this case was remanded in May 2020, the Board requested that the AOJ obtain an opinion from a VA examiner concerning whether it was at least as likely as not that the Veteran had a cervical spine disability, to include strain manifested by pain on movement after repetitive use, that was caused by or otherwise related to service. In so doing, the examiner was instructed to reconcile his/her opinion with the Veteran’s statements regarding the onset and continuity of his symptoms since service, “including an analysis of all the Veteran’s neck injuries, complaints and diagnoses both in service and post service, and the May 2013 VA examination finding pain on movement after service.” Pursuant to the May 2020 remand, the AOJ obtained a medical opinion later that same month. The examiner acknowledged that the Veteran had been diagnosed with cervical strain based on a VA examination dated in May 2013, but opined that it was less likely than not that his condition was related to service. In support of his opinion, the May 2020 VA examiner noted two entries in the Veteran’s service treatment records reflecting neck pain; one in September 1993, when there were normal cervical spine films, and another in June 1996 that mentioned pain from the lower back to the cervical region, with no neck films. The examiner noted that no diagnosis specific to the neck was recorded in those reports, but that the records would be consistent with a muscle strain. As to the link between in-service strain and the Veteran’s current condition, the examiner noted that he saw no in-service medical records after the record in June 1996 indicating an ongoing cervical spine condition temporally related to service. The examiner further noted that the available post-service medical records made no mention of an ongoing cervical spine condition until his VA examination in May 2013. In so finding, the examiner noted that a November 2009 medical note mentioned no active neck condition; that an active problem list from December 2012 mentioned no neck condition; and that a January 2018 medical note made no mention of an active or current neck condition. On that basis, the examiner stated that it would be difficult to state that the Veteran’s complaint of neck pain on the May 2013 VA examination would be related to his cervical strain in service. Unfortunately, it appears that the examiner’s review of the record may not have been complete. Specifically, in arriving at his opinion, the examiner made no mention of the Veteran’s complaint of neck pain in a July 2010 VA primary care note, a September 2010 VA occupational therapy consultation note, an October 2012 VA nursing triage note, a November 2012 VA SATP nursing note, or a January 2013 VA nursing triage note. Nor did the examiner make reference to complaints of neck pain in an October 2015 VA admission evaluation note, an October 2015 VA primary care note, a November 2015 VA primary care note, or a December 2015 VA physical therapy note. As it appears that the examiner’s opinion may have been based on an incomplete review of the record, further development is required. This matter is REMANDED for the following action: 1. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 2. After all of the foregoing development has been completed to the extent possible, make arrangements to provide the record on appeal to the VA examiner who previously offered opinions with respect to the etiology of the Veteran’s cervical spine disability in May 2020. The examiner should be asked to review the expanded record and prepare a supplemental report with respect to the matter of whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran has had a cervical spine disability at any time since August 2012 (when he filed his claim for service connection) that had its onset during, or is otherwise related to, service. In providing a rationale, the examiner must reconcile his/her opinion with the Veteran’s statements regarding the onset and continuity of his symptoms since service, including an analysis of all of the Veteran’s neck injuries, complaints and diagnoses, both in service and post service, and the May 2013 VA examination finding of pain on movement after repetitive use. In this regard, the examiner’s attention is drawn to the Veteran’s complaints of neck pain in a July 2010 VA primary care note, a September 2010 VA occupational therapy consultation note, an October 2012 VA nursing triage note, a November 2012 VA SATP nursing note, a January 2013 VA nursing triage note, an October 2015 VA admission evaluation note, an October 2015 VA primary care note, a November 2015 VA primary care note, and a December 2015 VA physical therapy note. If the May 2020 examiner is no longer employed by VA or is otherwise unable to provide the opinion(s) requested, arrange to obtain the requested information from another qualified examiner. The need for another examination and/or telephonic or video interview of the Veteran is left to the discretion of the examiner(s) selected to offer the requested opinions. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issue remaining on appeal should be readjudicated based on the entirety of the evidence. If the benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Willis, 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.