Citation Nr: 21010585 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 15-31 361A DATE: February 25, 2021 REMANDED Entitlement to a rating in excess of 20 percent for cervical strain is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from September 1995 to April 1999. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a July 12, 2014 rating decision which continued a 20 percent rating for the neck disability. In November 2018, a videoconference hearing was held before the undersigned; a transcript is in the record. In December 2018, the case was remanded for additional development. Entitlement to cervical strain in excess of 20 percent is remanded. In his November 2018 hearing testimony, the Veteran indicated that his service-connected neck disability had worsened since he was last previously examined by VA. The Board’s remand the following month noted that the diagnosis of disc disease suggested (when the previous diagnosis was cervical strain) suggested worsening and requested development for a contemporaneous examination to assess the disability and records of the Veteran’s private treatment. The remand specifically indicated that because the Veteran had reported flare-ups, the examiner should ascertain the frequency and duration of the flare-ups and opine regarding the additional impairment of function that is shown/would be expected during the flare-ups. A March 2019 treatment report notes the Veteran’s complaint of neck pain radiating to both upper extremities. On January 2020 VA examination, the Veteran reported pain along the occipital area, down the cervical spine and into the trapezius area, and that the pain was constant, with intermittent numbness/tingling from the neck into his hands throughout the day and persistent stiffness that affected neck rotation. He also testified that he felt he had a weakened. Grip. The examiner noted that a May 2019 cervical X-ray revealed “marginal” osteophytes at the C5-6 level. The examiner opined that there were no other significant abnormalities, including disc protrusion or extrusion or disc osteocomplex; no medical evidence of incapacitating episodes of cervical disc disease or ankylosis; and also no objective medical evidence to support neurological symptoms related to the cervical spine. The provider did not account for (reconcile the conclusions with) the noted complaints of radiating pain to the extremities, intermittent numbness/tingling, and feeling of weakened grip. The examiner also did not respond to the Board specific remand request (noting the Veteran’s earlier reports of flare-ups) to elicit information regarding (identify) the nature, frequency, and duration of flare-ups on to comment on the nature and degree of severity of additional functional impairment that is present during flare-ups. Therefore, the examination and opinion are less than substantially compliant with the remand directives (See Stegall v. West, 11 Vet. App. 268, 271 (1998)), and development for an addendum medical advisory opinion is necessary. The matter is REMANDED for the following: 1. Secure for the record all updated-to-the present records of VA evaluations and treatment the Veteran has received for a cervical spine disability (any not already in the record), specifically including all such records since September 2019. 2. After the above development is completed, arrange for the Veteran’s claims file to be returned to the January 2020 VA examiner for review and an addendum opinion. [If that provider is unavailable, arrange for another appropriate clinician to review the record, and provide the clarifying opinion sought. And if further examination of the Veteran by an appropriate clinician is deemed necessary for response to an opinion sought, such should be arranged.] The opinions should include responses to the following. (a) Reconcile the conclusion that the Veteran does not have neurological manifestations of his cervical spine disability, with his reported complaints ot radiating pain to the upper extremities, tingling, numbness, and perception of weakened grip. [If neurological manifestations remain opined to not be shown, explain why those complaints do not support that there are neurological manifestations. (b) Considering the Veteran’s reports of flare-ups on prior VA examinations, determine the frequency and duration of those flare-ups and describe, to the extent possible, nature and degree of additional functional impairment due to the neck disability during the flare-ups, accounting for pain, incoordination, weakened movement, and excess fatigability on use, to the extent possible, reporting such impairment in terms of additional degrees of limitation of motion. [If an opinion cannot be provided without resort to mere speculation, indicate whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts),or a deficiency in the record or the examiner (additional facts are required, or the examiner does not have the needed knowledge or training).] All opinions must include rationale that cites to supporting factual data and medical principles. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Fabian Lokenauth, 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.