Citation Nr: 21011943 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 13-15 377 DATE: March 3, 2021 ORDER Entitlement to an initial rating of 20 percent but no higher for right lower extremity radiculopathy is granted. Entitlement to an initial rating of 20 percent but no higher for left lower extremity radiculopathy is granted. Entitlement to an initial rating in excess of 20 percent for right upper extremity radiculopathy is denied. Entitlement to total disability due to individual unemployability (TDIU) is denied. REMANDED Entitlement to service connection for dizziness (also claimed as a neurological disorder) is remanded. Entitlement to service connection for right knee disability is remanded. Entitlement to service connection for brain disability is remanded. Entitlement to service connection for migraines to include as secondary to the Veteran's service-connected disabilities is remanded. FINDINGS OF FACT 1. The preponderance of the probative evidence of record establishes that for the entire period on appeal, the Veteran’s right lower extremity radiculopathy was manifested by no more than moderate neuralgia of the sciatic nerve. 2. The preponderance of the probative evidence of record establishes that for the entire period on appeal, the Veteran’s left lower extremity radiculopathy was manifested by no more than moderate neuralgia of the sciatic nerve. 3. The preponderance of the probative evidence of record establishes that for the entire period on appeal, the Veteran’s right upper extremity radiculopathy was manifested by no more than mild incomplete paralysis of the upper radicular group. 4. The preponderance of the probative evidence establishes that the Veteran’s service-connected disabilities do preclude him from securing and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. For the entire period on appeal, the criteria for entitlement to an initial rating of 20 percent but no higher for right lower extremity radiculopathy are met. 38 C.F.R. §§ 4.7, 4.124, Diagnostic Code 8720. 2. For the entire period on appeal, the criteria for entitlement to a rating of 20 percent but no higher right lower extremity radiculopathy are met. 38 C.F.R. §§ 4.7, 4.124, Diagnostic Code 8720. 3. The criteria for entitlement to an initial rating in excess of 20 percent for right upper extremity radiculopathy are not met. 38 C.F.R. §§ 4.7, 4.124, Diagnostic Code 8510. 4. The criteria for service connection for TDIU are not met. 38 U.S.C. §§ 1110, 1131, 1155, 5107; 38 C.F.R. §§ 3.102, 3.158, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1991 to February 1996. These matters come before the Board of Veterans’ Appeals (Board) on appeal from June 2011 and May 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). An August 2017 Board decision remanded the issues on appeal. A remand by the Board imposes a concomitant duty to ensure compliance with the terms of the remand. Where the remand orders are not complied with, the Board itself errs in failing to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Upon review, the Board finds that the remand directives have been substantially complied with. The Board notes that the AOJ requested the Veteran submit any relevant private treatment records or submit information with which VA can assist the Veteran in obtaining private treatment records. VA requested records for which the Veteran submitted a proper release. The duty to assist is not a one-way street. If a Veteran desire help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining evidence. Wood v. Derwinski, 1 Vet. App. 190 (1991). Thus, the Board finds that VA has satisfied the duty to assist. No further notice or assistance to the Veteran is required to fulfill VA’s duty to assist in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Veteran’s claims for entitlement to service connection for dizziness (also claimed as a neurological disorder), right knee disability, brain disability and migraines are discussed in the remand section below. Increased Rating General Rating Principles Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Board will consider not only the criteria of the currently assigned diagnostic code, but also the criteria of other potentially applicable diagnostic codes. Rating Principles: Lower Extremity Radiculopathy The Veteran is currently service connected for radiculopathy of the bilateral lower extremities with a rating of 10 percent for right lower extremity radiculopathy and 10 percent left lower extremity radiculopathy From November 16, 2010 to February 21, 2013 and a rating of 20 percent for each lower extremity beginning February 21, 2013 thereafter, under diagnostic code 8720 for neuralgia of the sciatic nerve. Under diagnostic code 8720, a rating of 10 percent is warranted for mild neuralgia of the sciatic nerve; a rating of 20 percent is warranted for moderate neuralgia of the sciatic nerve; a rating of 40 percent is warranted for moderately severe neuralgia of the sciatic nerve and a rating of 60 percent is warranted for severe neuralgia with marked muscular atrophy. A rating of 80 percent is warranted for complete paralysis of the sciatic nerve with foot dangle and drop, no active movement possible of the muscle below the knee and flexion of the knee weakened or (very rarely) lost. Rating Principles: Upper Extremity Radiculopathy The Veteran is currently service connected for radiculopathy of the right upper extremity associated with the cervical spine, with a rating of 20 percent beginning February 6, 2017 under diagnostic code 8510. The Veteran is right arm dominant; therefore, the right arm is considered a major joint. Under diagnostic code 8510 a rating of 20 percent is warranted for mild incomplete paralysis of the upper radicular group of a major joint. A rating of 40 percent is warranted for moderate incomplete paralysis of the major joint upper radicular group. A rating of 50 percent is warranted for severe incomplete paralysis of the major joint upper radicular group. A rating of 70 percent is warranted for complete paralysis of the major joint upper radicular group with all shoulder and elbow movement lost or severely affected and hand and wrist movements not affected. The terms “mild” “moderate” “moderately severe” and “severe” are not defined in the Rating Schedule. Thus, rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Analysis 1. Entitlement to an initial rating of 20 percent but no higher for right lower extremity radiculopathy. 2. Entitlement to an initial rating of 20 percent but no higher for left lower extremity radiculopathy The Veteran contends that he is entitled to an initial rating in excess of 10 percent for his right lower extremity radiculopathy and left lower extremity radiculopathy for the period prior to February 21, 2013. The Veteran further contends that he is entitled to a rating in excess of 20 percent for right lower extremity radiculopathy and left lower extremity radiculopathy beginning February 21, 2013 and thereafter. Based on the preponderance of the probative evidence of record, and notwithstanding the Veteran’s contentions, the record establishes entitlement to a rating of 20 percent but no higher for right lower extremity radiculopathy and left lower extremity radiculopathy for the entire period on appeal. Entitlement to a rating in excess of 10 percent for right lower extremity radiculopathy and left lower extremity radiculopathy prior to February 21, 2013. The Veteran was afforded a VA examination for his knee in March 2011. The examiner noted that the Veteran’s spinal pain radiated down both legs, with pain being worse on the left with prolonged sitting and standing. The radiating pain was described as soreness, aching pain in legs with the pain that radiated up the spine being noted as sharp needle-like pain. The Veteran remained able to walk a quarter a mile but was noted to have been issued a handicap sticker by his primary care provider to minimize walking. The Veteran also noted some increased absenteeism with an inability to engaged in prolonged standing. The examiner noted that the Veteran’s knee disability resulted in decreased ability to perform daily chores such as making the bed and vacuuming, and difficulty tying shoes due to low back pain. The Veteran was noted to have a normal gait, but also had some crepitus. Further while the Veteran’s disability impacted his daily activities such as chores, shopping, exercise and driving, the impact on these daily activities was characterized as no more than moderate. The Board finds the March 2011 VA examination adequate, as it appropriately considers the objective findings, subjective statements and all evidence of record. April 2011 VA treatment records note that the Veteran reported back pain with intermittent weakness. The Veteran reported hip flexor weakness with some difficulty getting out of a chair. He denied symptoms of numbness but reported that the frequency of his symptoms had increased. The Veteran also reported that his pain radiated to his lower back and legs. In June 2011, the Veteran reported that he developed weakness in both legs with associated numbness and tingling approximately three months prior. He reported that although his symptoms were initially sporadic, they became consistent at night while sleeping, and hindered his sleep. The Veteran reported that his symptoms were worse with sitting and laying down and alleviated with Percocet and tramadol, which helped with sleep. An MRI showed mild disc desiccation along with stable anterior compression of the vertebral body. At subsequent June 2011 VA appointment approximately ten days later, the Veteran reported that his back always hurts, and he occasionally experiences leg numbness and tingling. During October 2011 VA treatment the Veteran endorsed leg pain characterized as sharp and aching. The Veteran reported that his pain interfered with sleep, appetite, energy, physical activity, emotions, relationships and activities of daily living. July 2012 VA neurology treatment records note that the Veteran reported difficult sleeping for the past two years, with leg paresthesias described as numbness and pins and needles. The Veteran reported that his paresthesias were diffuse on both legs and feet and he admitted to occasional bilateral lower extremity weakness. However, he denied any falls. November 2012 VA treatment records note that during a neurological appointment the Veteran reported that since October 2010 he has experienced occasional weakness and tingling of his lower extremities, worse when sitting, better when walking. Ultimately, for the period prior to February 21, 2013, the evidence of record shows symptoms of radiating pain with leg weakness and numbness. The Veteran’s symptoms impacted his ability to perform household chores and the Veteran was noted to have some difficulty rising from a chair. Additionally, evidence notes that the Veteran was prescribed a handicap sticker, to reduce the Veteran’s need to walk long distances. Subjectively, the Veteran reported that over time his symptoms were progressively worse and reported symptoms of leg tingling and numbness which interfered with his ability to sleep. Based on the evidence of record the Board finds that prior to February 21, 2013, the Veteran’s symptoms were moderate in severity and warrant a rating of 20 percent. However, the evidence does not support a finding that the Veteran’s symptoms were moderately severe or severe to warrant a rating in excess of 20 percent. In rendering a decision, the Board has considered all evidence of record including the Veteran’s subjective complaints. The Board finds the Veteran’s lay statements competent and credible as lay persons are competent to report information to which they have knowledge of facts or circumstances and matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. As such, the Board affords weight to the Veteran’s lay statements. Nonetheless, even in light of the Veteran’s subjective statements of pain and weakness, for the reasons discussed above, the evidence does not substantiate entitlement to a rating in excess of 20 percent for moderate neuralgia of the sciatic nerves for the period prior to February 21, 2013. Notably, while the Board has considered all evidence of record, the March 2011 VA examination was for the Veteran’s knee disability, not his lumbar spinal disability which is associated with the Veteran’s radiculopathy. The Veteran is separately service connected for his right knee disability, which is not before the Board on appeal and contemplates the Veteran’s symptoms associated with his right knee. Thus, as the examination notes symptoms of radiculopathy and subsequent treatment records noting ongoing radiculopathy symptoms with pain and some difficulty rising for a chair, the Board finds that these symptoms warrant a 20 percent rating for moderate severity. However, based on no evidence of lower extremity weakness, incapacitating episodes or other moderately severe or severe symptoms, entitlement to a rating of 20 percent but no higher for the period prior to February 21, 2013 is granted. Entitlement to a rating in excess of 20 percent for right lower extremity radiculopathy and left lower extremity radiculopathy beginning February 21, 2013 and thereafter. The Veteran was afforded a general VA examination in February 2013. The Veteran was noted to have lumbar radiculopathy of the bilateral lower extremities, diagnosed in 1996. The Veteran was noted to have normal sensation to light touch of the bilateral lower extremities. The Veteran’s radiculopathy did not cause any constant pain but was noted to cause severe intermittent pain of the bilateral lower extremities as well as moderate paresthesia and numbness of the bilateral lower extremities. The examiner indicated that the Veteran’s radiculopathy involved the sciatic nerve root and that the severity of the Veteran’s radiculopathy was moderate, bilaterally. No other neurologic abnormalities were noted. Subjectively the Veteran reported working full time, for over a year. He reported missing one day of work per week due to neck, back and headache pain but also noted that if he were not working a government sponsored training job, his increased absenteeism would prevent him from maintaining both physical and sedentary labor. The Board affords probative weight to this examination as it considers both the objective findings and the Veteran’s subjective complaints. May 2013 VA treatment records note complaints of leg tingling and numbness in the side of both legs. The Veteran reported that it felt like his legs were falling asleep. He also reported missing a few days of work. October 2013 VA treatment records note that the Veteran reported developing intermittent weakness, tingling and numbness of the bilateral lower extremities most prominent on his feet. He described as feeling like jelly in his legs. The Veteran reported that the spells can last from seconds, to 24 hours and he can develop episodes at any time. He endorsed Lhermitte’s’ signs but denied any symptoms when having hot showers. February 2015 VA treatment records note that the Veteran endorsed intermittent bilateral paresthesia of the legs. During an August 2015 VA neurology appointment, treatment records note that the Veteran reported an incident where he was walking, his leg became weak and he was no longer able to walk on it. The Veteran reports that he sat down for 15 to 20 minutes because he could no longer ambulate, after which the leg strength began to improve. In October 2015, VA treatment records note that the Veteran reported occasionally having episodes of tingling in his feet and les bilaterally, associated with weakness. During a February 2017 VA examination for his back, the Veteran was noted to have constant radicular pain in the right lower extremity and the left lower extremity. The Veteran’s right lower extremity pain was noted as severe, while the Veteran’s left lower extremity pain was characterized as mild. The Veteran was also noted to have mild paresthesia of the right lower extremity, no paresthesia of the left lower extremity, mild numbness of the right lower extremity and no numbness of the left lower extremity. The examiner asserted that the severity of the Veteran’s bilateral lower extremity radiculopathy was mild. Similarly, a subsequent July 2018 VA examination noted radiculopathy with mild constant pain, mild intermittent pain, mild paresthesia and mild numbness bilaterally. By June 2019 VA treatment records note that the Veteran’s chronic low back pain with radiculopathy was stable and controlled with medication. While evidence from February 2013 and thereafter continue to note ongoing symptoms of radicular pain with lower extremity tingling and numbness, the evidence of record does not show more than moderate symptoms. Specifically, VA examination have characterized the severity of the Veteran’s symptoms as no more than moderate. Further, while the Veteran has consistently reported symptoms of lower extremity weakness and numbness, he has denied any falls. Although the Veteran was noted to have constant severe right lower extremity radicular pain, the examiner noted that the overall severity of the Veteran’s right lower extremity radiculopathy was no more than moderate. This is further evidence by the fact that the record does not show that the Veteran’s radiculopathy results in less than 4/5 muscle strength, there is no evidence of muscle atrophy or abnormal gait. Further, by June 2019, the Veteran’s symptoms are noted as stable. Ultimately, even considering the Veteran’s lay statements, which the Board finds probative, and the Veteran’s symptoms of pain difficulty in prolonged standing and walking the evidence of record does not establish entitlement to a rating in excess of 20 percent for moderate neuralgia of the sciatic nerve. For the entire period on appeal, entitlement to a rating of 20 percent but no higher for right lower extremity radiculopathy is granted. For the entire period on appeal, entitlement to a rating of 20 percent but no higher for left lower extremity radiculopathy is granted. 3. Entitlement to an initial rating in excess of 20 percent for right upper extremity radiculopathy. The Veteran was initially service connected with a rating of 20 percent for his right upper extremity radiculopathy, associated with cervical spine strain effective February 6, 2017 under diagnostic 8510. The Veteran contends that he is entitled to an initial rating in excess of 20 percent for his right upper extremity radiculopathy. For the reasons discussed below, the preponderance of the probative evidence of record does not establish more than mild severity of the right upper extremity radiculopathy and a rating in excess of 20 percent is not warranted. A July 2018 VA examination for the Veteran’s cervical spine notes a diagnosis of right upper extremity radiculopathy. Subjectively, the Veteran reported constant neck pain and bilateral upper extremity tightness, sharp pain, numbness and tingling. The Veteran reported that due to his neck disability he cannot play sports, drive, sit in front of the computer or TV for a long time, cannot sleep due to difficulty finding position to sleep in, cannot ride a bicycle and cannot do household chores. Objectively the Veteran was noted to have mild constant pain, mild intermittent pain, mild paresthesia and mild numbness of the right upper extremity involving the upper radicular group. The severity of the Veteran’s radiculopathy was noted as mild. The Veteran did not require the use of an assistive device for his right upper extremity radiculopathy. While subsequent treatment records continue to note symptoms of upper radicular pain, treatment records do not show any muscle atrophy, further reduced muscle strength or worsening of the Veteran’s upper extremity radiculopathy. Similarly, the Veteran has not alleged worsening of his right upper extremity radiculopathy since his July 2018 VA examination. Ultimately based on the evidence of record, including the Veteran’s lay statements and subjective symptoms the record does not establish any more than mild right upper extremity symptoms. While the Veteran reports some severe limitations of such as difficulty sitting in front of the computer or TV for a long time, sleep disturbance, inability to ride a bicycle and inability to do household chores Specifically, the July 2018 VA examination characterizing the Veteran’s symptoms as no more than mild, and the evidence does not show right upper extremity strength less than 4/5 or muscular atrophy. While the record notes some functional loss, the Veteran’s pain remained characterized as no more than mild. Entitlement to a rating in excess of 20 percent for right upper extremity radiculopathy is denied. TDIU Legal Criteria Total disability will be considered to exist where there is present any impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation because of service-connected disabilities, provided that the veteran meets the schedular requirements. If there is only one service-connected disability, this disability should be rated at 60 percent or more; if there are two or more disabilities, at least one should be rated at 40 percent or more with sufficient additional service-connected disabilities to bring the combination to 70 percent or more. For the purposes of one 60 percent disability or one 40 percent disability in combination, the following will be considered as one disability (1) Disabilities of one or both upper extremities, or of one or both lower extremities including the bilateral factor, if applicable (2) disabilities resulting from common etiology or a single accident (3) disabilities affecting a single body system (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a). The ability to work sporadically or obtain marginal employment is not substantially gainful employment. 38 C.F.R. § 4.16(a); Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). Marginal employment, i.e., earned annual income that does not exceed the poverty threshold for one person, is not considered substantially gainful employment. 38 C.F.R. § 4.16(a). In determining whether unemployability exists, consideration may be given to the veteran’s level of education, special training, and previous work experience, but it may not be given to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Analysis 4. Entitlement to total disability due to individual unemployability (TDIU) is denied. For the reasons discussed below, the Veteran’s TDIU claim is considered abandoned, and entitlement to TDIU is denied. A Veteran is only entitled to TDIU if the evidence shows that the Veteran is unable to obtain or maintain substantial gainful employment as a result of his service-connected disabilities. Here, evidence of record as recently as November 2018 shows that the Veteran is employed full time. Similarly, treatment records from October 2017, March 2014 and May 2013 indicate that the Veteran is employed. It is unclear from the evidence whether the Veteran’s employment constitutes substantial gainful employment. However, the Board’s August 2017 decision asked the Veteran to complete an updated VA form 21-8490. The AOJ sent a letter to the Veteran and his representative in November 2017 requesting that he complete an updated VA form 21-8940, to date, neither the Veteran nor his representative has returned a completed form or offered any additional information regarding the Veteran’s employment history. Where evidence requested in connection with a claim is not furnished within one year after the date of the request, the claim will be considered abandoned. After the expiration of one-year, further action will not be taken unless a new claim is received. Here, because neither the Veteran nor his representative have furnished the information that was requested more than years ago, the Veteran’s claim for entitlement to total disability due to individual unemployability is deemed abandoned and must be denied. REASONS FOR REMAND 4. Entitlement to service connection for dizziness claimed as a neurological condition. The Veteran’s claim for entitlement to service connection for dizziness, claimed as a neurological condition must be remanded for an addendum opinion. The August 2017 Board decision remanded the issue of entitlement to service connection for dizziness for further development, namely a VA examination. The remand directives instructed the agency of original jurisdiction (AOJ) to schedule the Veteran for an ENT examination to determine the nature and etiology of his dizziness. The examiner was directed to diagnose all disorders manifested by dizziness and state whether it is at least as likely as not that the diagnosed disorder arose in service or is otherwise related to service, to include complains of dizziness reported in October 1994 and during an August 1995 separation examination. Following the remand, the Veteran was afforded an examination for ear conditions including vestibular and infectious conditions in August 2018. The examiner opined that the Veteran’s dizziness was less likely than not incurred in or caused by the claimed in-service injury event or illness. As supporting rationale, the examiner asserted that the Veteran’s condition was acute with no evidence of chronicity of care. Specifically, the examiner noted that the Veteran separated form service in 1996 and claimed dizziness for the first time in 2011, 15 years post military service. The examiner further noted that there are no medical records showing chronicity of care over 15 years after separation from service, therefore a nexus has not been established. This opinion is inadequate. The examiner’s statement that the Veteran claimed dizziness for the first time in 2011 is inaccurate. VA treatment records show that post service, the Veteran reported symptoms of dizziness and weakness in May 2005, December 2009 and July 2010. As the examiner’s opinion is based on an inaccurate factual premise and did not consider all of the evidence of record, remand for an addendum opinion is warranted. 5. Entitlement to service connection for right knee disability is remanded. Remand is warranted for a new VA examination of the Veteran’s right knee. A July 2018 VA examination for the Veteran’s knee and lower leg conditions notes that the x-ray imaging shows osteoarthritis of the right knee. The examiner notes that the diagnosis is a completely new and unrelated entity that has developed since the last examination or a diagnosis that was not identified previously. As supporting rationale, the examiner notes that there is no peer reviewed evidence that supports the claim that arthritis in one knee causes arthritis in the other knee. The examiner’s opinion and supporting rationale does not address whether the Veteran’s right knee disability was incurred in or caused by the Veteran’s military service. Moreover, the Board instructed that the examiner provide an opinion regarding whether the Veteran’s right knee disability was caused or aggravated by a service-connected disability. Notable here, the Board’s remand directives defined aggravation as “permanently worsened beyond natural progression.” In compliance with the Board’s request, the examiner opined that there is no evidence that the Veteran’s knee disability has been permanently worsened beyond normal progression. However, since the August 2017 Board decision, the Court of Appeals for Veterans Claims (CAVC) has held that aggravation does not require permanent worsening. Instead, aggravation includes any additional impairment in earning capacity or incremental increase in disability resulting from an already service-connected condition, regardless of its permanence. Ward v. Wilkie 31 Vet. App. 233 (2019). As such, remand is appropriate for a new opinion. 6. Entitlement to service connection for a brain condition (also claimed as white fluid around cells with increased lesions). 7. Entitlement to service connection for migraines to include as secondary to the Veteran's service-connected disabilities is remanded. The August 2017 Board opinion remanded the claim for entitlement to service connection for brain disorder and entitlement to service connection for headache disability for VA opinions, to include opinions regarding whether the Veteran’s brain disability and headache disability were aggravated by the Veteran’s service connected disabilities. The Board’s remand directives defined aggravation as “permanently worsened beyond natural progression.” As discussed above, the Court of Appeals for Veterans Claims (CAVC) has held that aggravation does not require permanent worsening. As such, remand is appropriate for new VA opinions. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records. 2. Obtain an addendum opinion from an appropriate clinician to determine the etiology of the Veteran’s dizziness. The claims file should be reviewed by the examiner in conjunction with the examination. Following a review of the claims file, the examiner should provide the following: (a) Diagnose all disorders manifested by dizziness. (b) For each diagnosed disorder, state whether it is at least as likely as not (50 percent probability or greater) that the diagnosed disorder arose in service, or is otherwise related to service, or was aggravated beyond its natural progression by a service-connected disability. For the purpose of this examination, the term aggravation shall mean any increase in disability, regardless of its permanence. In rendering an opinion, the examiner must consider all evidence of record, to include complaints of dizziness reported in October 1994 and during an August 1995 separation examination as well as post service complaints of dizziness. The examiner should explain the medical basis for any conclusion reached. 3. Schedule the Veteran for a VA joints examination to determine the nature and etiology of any right knee disability, including right knee arthritis. The claims file should be reviewed by the examiner in conjunction with the examination. Any medically indicated tests should be accomplished and the results reported. Following a review of the claims file, the examiner should provide the following: (a) Diagnose any right knee disability. Specifically, state whether the Veteran has signs and symptoms of a right knee disability separate from his lower extremity radiculopathy. (b) For each right knee disability diagnosed, state whether it is at least as likely as not (50 percent probability or greater) that the diagnosed disorder arose in service or is otherwise related to service. (c) state whether it is at least as likely as not (50 percent probability or greater) that any right knee disability was caused by a service-connected disability. Please explain why or why not. (d) State whether it is at least as likely as not (50 percent probability or more) that it has been aggravated as a result of any service-connected disability. The term aggravation shall mean any incremental increase in disability regardless of its permanence. 4. Schedule the Veteran for a VA neurological examination. The claims file should be reviewed by the examiner in conjunction with the examination. Any medically indicated tests should be accomplished and the results reported. Following a review of the claims file, the examiner should provide the following: (a) diagnose any brain and headache disabilities found on examination and shown in the record. The examiner should address the significance of the brain lesions found on imaging in 2007. (b) For each disability diagnosed, state whether it is at least as likely as not (50 percent probability or greater) that the diagnosed disability arose in service or is otherwise related to service. In providing the foregoing opinion, the examiner should address the Veteran’s March and April 1997 reports of personality changes and reference to cognitive changes following his low back injury in service. (c) If not related to service, for each diagnosed disability, state whether it is at least as likely as not (50 percent probability or greater) that any brain or headache disability was caused by a service-connected disability. Please explain why or why not. In providing the foregoing, the examiner should address the Veteran’s complaints of headaches related to his neck pain during VA examinations, as well as evidence suggesting the Veteran’s headaches could be related to his brain lesions. (d) State whether it is at least as likely as not (50 percent probability or more) that the Veteran’s brain disorder or headaches have been aggravated by a service-connected disability. For the purpose of this examination, the term aggravation shall mean any incremental increase in disability as a result of a service-connected disability regardless of its permanence. Please explain why or why not. Further, if possible, quantify the degree of aggravation beyond the baseline level of disability. A complete rationale for the opinions rendered must be provided. If you cannot provide the requested opinions without resorting to speculation, please expressly indicate this and provide a supporting rationale as to why that is so (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.). Jennifer White Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Wimbish, 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.