Citation Nr: 21012432 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 10-31 371 DATE: March 4, 2021 REMANDED Entitlement to service connection for a cervical spine disability (claimed as cervical myelopathy), to include as secondary to service-connected disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1968 to June 1970. This matter is on appeal from a November 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded in March 2018 and March 2019 decisions by the Board of Veterans’ Appeals (Board). The Board notes that the issue on appeal was previously characterized as entitlement to service connection for cervical myelopathy. However, in light of the Veteran’s assertions and the evidence of record, the Board has recharacterized the issue more broadly to include any cervical spine disability. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009). The case was remanded for an addendum opinion in March 2019. On remand, the examiner was requested to consider evidence relating to a 1984 cervical laminectomy and April 1970 service treatment records noting cervical adenitis in service. The examiner was also asked to opine whether the Veteran’s cervical myelopathy was caused or aggravated by service-connected non-Hodgkin’s lymphoma or myelodysplastic syndrome with history of pancytopenia and splenomegaly. See March 2019 Board decision. Following remand, another VA examination was performed in July 2020. The examiner noted the reported history of a motor vehicle accident in 1986, followed by anterior fusion. He reported ongoing neck pain and underwent additional cervical spine surgery in 1997. A 2013 MRI study showed cervical myelomalacia and thinning of the cord with increased signal at C5-C6. Current symptoms include constant low-level aching pains with more severe pain with extending the spine or rotating the head. He also reported swelling and tingling in the hands and right foot. The Veteran reported he cannot look up or fully rotate the head and described difficulty driving due to inability to check his blind spots. A physical examination revealed decreased range of motion with right and left lateral flexion and right and left lateral rotation. Pain was noted on examination causing functional loss. See July 2020 VA examination report. The July 2020 examiner stated that the Veteran has a diagnosis of cervical myelomalacia which is not the same as cervical myelopathy. Cervical myelomalacia is a central nervous system condition, not a neck condition. The examiner diagnosed degenerative disc disease status-post 1997 spinal fusion. The examiner opined that the Veteran’s claimed cervical myelopathy disability is less likely than not incurred in or caused by service, explaining that his service treatment records are negative for any neck injuries or complaints during active service and the April 1970 separation examination was normal. Regarding secondary service connection, the examiner reiterated that there is no objective evidence of cervical myelopathy and the 2013 MRI indicated myelomalacia, which is a different diagnosis. The examiner stated that the Veteran’s myelomalacia was caused by the degenerative disc disease and cervical fusion. The examiner explained that there is no physiological link between development of non-Hodgkin’s lymphoma or myelodysplastic syndrome and myelomalacia. In addition, the 2018 PET scan did not reveal any lesions or growth in the cervical spine that could be causing a “mass-effect” or some similar effect on the cervical spine or cord. See July 2020 VA examination report. While the Board sincerely regrets further delay, the Board finds the July 2020 examination is inadequate in several respects and it is therefore necessary to remand for a clarifying medical opinion. First, with regard to direct service connection, the examiner did not consider the April 1970 service treatment records noting cervical adenitis during service, nor did the examiner consider the July 2005 private treatment records noting the history of a cervical laminectomy in 1984. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order). In addition, the examiner did not address the aggravation prong of secondary service connection except to state that there is no objective evidence of cervical myelopathy. The Board observes that the record does contain a diagnosis of cervical myelopathy during the relevant appeal period. If the cervical myelopathy was misdiagnosed or resolved, then the examiner should explain so in a clarifying medical opinion. The Board also observes that even if the Veteran does not have cervical myelopathy, the examiner noted decreased range of motion and pain causing functional loss described as difficulty driving due to the inability to rotate his head to check blind spots and difficulty navigating stairs, creating a risk of falling. Pain alone, without a specific diagnosis or identifiable disease, may cause a functional impairment and therefore qualify as a disability for VA purposes. See Saunders v. Wilkie, 886 F.3d 1356, 1362 (Fed. Cir. 2018). Although the examiner stated that there is no “physiologic link” between development of non-Hodgkin’s lymphoma and/or myelodysplastic syndrome and cervical myelomalacia, he failed to address whether a cervical spine disability was worsened or aggravated by the Veteran’s service-connected disabilities as required under 38 C.F.R. § 3.310. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (a medical opinion is inadequate when it fails to adequately address the question of aggravation and indicating that findings of “not due to,” “not caused by,” and “not related to” a service-connected disability are insufficient to address the question of aggravation under § 3.310(b)). Before awarding service connection for any disability of the cervical spine, the Board must have a complete picture of all the Veteran’s cervical spine disabilities and their probable etiologies. Accordingly, on remand, an adequate opinion must be obtained. For these reasons, an addendum medical opinion is needed to determine the nature and etiology of the Veteran’s cervical spine disability. The matter is REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his cervical spine that are not already of record. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. After completing the foregoing development, the AOJ should refer the Veteran’s claims file to a suitably qualified VA examiner for a clarifying opinion as to the nature and etiology of any current cervical spine disabilities. A physical examination is only needed if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and statements. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify all cervical spine disabilities. If any previously diagnosed cervical spine disability is not found, the examiner should address whether the disability was misdiagnosed or has resolved. The examiner should also state whether there is any functional impairment caused by any cervical spine pain. Evidence of pain alone that causes functional impairment, even without a specific diagnosis or identifiable disease, may constitute a disability for VA purposes. For each diagnosis identified or any functional impairment resulting from pain, the examiner should opine as to whether it is at least as likely as not that the disability manifested in or is otherwise causally or etiologically related to his military service, to include any injury and symptomatology therein. The examiner should also opine as to whether it is at least as likely as not that the Veteran has a current cervical spine disability that was caused by or aggravated by his service-connected non-Hodgkin’s lymphoma and/or myelodysplastic syndrome with history of pancytopenia and splenomegaly. In rendering his or her opinion, the examiner should address both the causation and aggravation questions in his or her rationale. In other words, even if the Veteran’s service-connected disabilities did not cause his current cervical spine disorder, the examiner should still address whether his service-connected disabilities could have worsened his cervical spine disorder. In rendering this opinion, the examiner should consider any evidence relating to the 1984 cervical laminectomy which was referenced in the July 2005 private treatment records; the April 1970 service treatment records noting cervical adenitis during service; and the Veteran’s lay assertions. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After completing these actions, the AOJ should conduct any other development as may be indicated by a response received as a consequence of the actions taken in the preceding paragraphs. B. G. LeMoine Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D.S. Chilcote, 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.