Citation Nr: 21013201 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 11-18 366 DATE: March 9, 2021 REMANDED Entitlement to service connection for a neck disorder, to include as secondary to service-connected PTSD or migraine headaches associated with his service connected TBI, is remanded. REASONS FOR REMAND The Veteran served on active duty for training from May 2005 to September 2006, active duty for special training from October 2008 to April 2009, and on active duty from April 2009 to April 2010. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an October 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. Jurisdiction resides with the RO in Des Moines, Iowa. In January 2015 the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. Sadly, the Veteran died in February 2018. In a March 2018 decision, the Board dismissed the current issue on appeal due to the death of the Veteran. Within one year, the AOJ recognized the substitution of the appellant, the legal guardian of the Veteran’s minor children, in the appeals pending before the Board. The appeal on the issue of entitlement to service connection for a neck disorder is again before the Board. 1. Entitlement to service connection for a neck disorder, to include as secondary to service-connected PTSD or migraine headaches associated with his service connected TBI is remanded. Though the Board regrets additional delay, remand is required for an adequate VA opinion. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A December 2020 VA medical opinion was provided to address the etiology of the Veteran’s cervical spine condition. The examiner provided a negative nexus opinion, acknowledging that the Veteran had been involved in an in-service explosion in September 2009 but noted that subsequent medical records were negative for complaints of cervical issues despite containing complaints of other orthopedic issues. The examiner determined that any neck pain following the blast had likely been transient as the Veteran did not complain of neck issues until the September 2011 VA examination. The examiner then noted that the Veteran sustained two cervical vertebral fractures in a motor vehicle accident (MVA) in 2012 and had ongoing problems thereafter. The examiner found that the Veteran had some neck symptoms at the September 2011 VA examination, but no definitive diagnosis was rendered at the time and imaging studies appeared normal. The examiner determined that any cervical damage was minimal based on the lack of documentation prior to the September 2011 VA examination when contrasted with the documentation of complaints regarding the cervical spine following the 2012 MVA. The examiner acknowledged anecdotal evidence of complaints for a neck condition following the September 2009 blast but there was no documentation of such issues. The examiner also stated that he had reviewed the ample medical documentation and there was no support for his having a neck condition due to the use of the helmet or loading heavy weaponry onto military vehicles. The examiner then stated that the Veteran’s service-connected PTSD and migraine headaches did not cause the Veteran’s neck condition, noting again that the cervical spine symptoms following the in-service blast had been transient and that PTSD, a mental health disorder, was not capable of causing a neck disorder. The examiner then stated that the migraine headaches did not cause the cervical condition as they are not normally related to the neck but are caused by hormonal changes, alcohol and caffeine, stress, etc. In a subsequent portion of the examination, the examiner stated that the note in October 2010 indicating that the Veteran had a problem with migraine headaches associated with his neck, was not borne out by the clinical examination of the neck which was unremarkable. There are other types of headache such as muscle tension or cervicogenic headaches that may relate to the neck, but not migraine headaches. The examiner then determined that the Veteran’s neck condition was not aggravated by PTSD or migraine headaches because the Veteran’s cervical condition was caused by an MVA. As the Veteran’s neck condition following the in-service blast was transient, there could not be aggravation of a condition that had been resolved. The Board finds that the examiner’s secondary service connection opinions are inadequate. First, the examiner provided no explanation for the statement that the cervical condition was less likely than not caused by PTSD because PTSD was not capable of causing a neck condition. Second, the examiner then determined that the Veteran’s neck condition was less likely than not aggravated by his service-connected PTSD or migraine headaches as the Veteran’s cervical condition had resolved following the in-service blast, and therefore could not be aggravated. The Board notes that this is not the standard for an aggravation opinion. The neck condition itself does not need to be caused by service in order to be considered for secondary service connection through aggravation. The Veteran has a current neck condition and service-connected conditions and he asserts that these conditions aggravate the neck condition. As such, the aggravation opinion provided by the examiner is inadequate and remand is required. The matters are REMANDED for the following action: Obtain an addendum opinion regarding the etiology of the claimed neck disorder from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. An explanation for all opinions expressed must be provided. (a.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that a neck disorder was caused or aggravated by the service-connected PTSD or migraine headaches. The examiner must address the following: 1) the Veteran’s lay testimony from at least 2010 documenting chronic neck pain that began in 2009 when he was injured in an explosion; 2) an October 2010 VA examination report noting that the Veteran’s neck condition was a problem associated with migraine headaches; and 3) the September 2011 VA TBI examination documenting findings of tenderness of the cervical spine, increased muscle tone and tension of the cervical extensors, and pain on range of motion testing of the cervical spine that existed prior to the 2012 accident. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Ashley Ki 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.