Citation Nr: 21014205 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 14-99 811A DATE: March 11, 2021 ORDER A rating higher than 40 percent for thoracolumbar pain with multilevel lumbar degenerative disc disease (lumbar spine disability) is denied. From February 9, 2011, a 30 percent rating, but no higher, for a degenerative disc disease of the cervical spine (cervical spine disability) is granted. FINDINGS OF FACT 1. The Veteran’s lumbar spine disability has not been manifested by unfavorable ankylosis of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine. 2. From February 9, 2011, the Veteran’s cervical spine disability has manifested in forward flexion to 10 degrees, but without unfavorable ankylosis of the entire cervical spine or unfavorable ankylosis of the entire spine. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 40 percent for a lumbar spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5237. 2. The criteria for a 30 percent rating, but no higher, for a cervical spine disability have been met, effective February 9, 2011. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1976 to March 1981. This appeal comes before the Board of Veterans Appeals (Board) from a June 2011 rating decision that continued the 20 percent rating for the cervical spine disability and the 40 percent rating for the lumbar spine disability. In November 2019, the appeal was previously remanded for further development. The Board finds that there has been substantial compliance with the prior Board remand directives. See Stegall v. West, 11 Vet. App. at 271 (1998). In July 2020, the Veteran’s rating for the cervical spine disability was increased to 30 percent, effective September 7, 2019. As higher ratings are still available both before and after the effective date of the grant, and the Veteran has not expressed satisfaction with the increased rating, the issue remains on appeal. See AB v. Brown, 6 Vet. App. 35, 39 (1993). During the pendency of the appeal, the rating criteria evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended, effective February 7, 2021. 85 Fed. Reg. 230 (November 30, 2020). However, the Veteran’s lumbar and cervical spine disabilities are rated under the General Formula for Disease and Injuries of the Spine, which did not change. The Board observes that Diagnostic 5243 for intervertebral disc syndrome was revised to only apply when there is disc herniation with compression and/or irritation of the adjacent nerve root. Nevertheless, although it appears that the new version of Diagnostic Code 5243 does not apply in this case, the Board will still consider the criteria for Intervertebral disc syndrome as the previous criteria is more favorable to the Veteran. Increased Rating 1. A rating higher than 40 percent for lumbar spine disability The Veteran contends that he is entitled to a 50 percent rating for his service-connected lumbar spine disability. See VA 21-526b, Veteran Supplemental Claim (February 2011). The Veteran’s lumbar spine disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Unfavorable ankylosis is defined as “a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching.” Id. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is “always” considered favorable ankylosis. Id. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. In evaluating any disability on the basis of limitation of motion, consideration is given to the actual degree of functional impairment imposed by pain, incoordination, weakness, fatigue, and lack of endurance with repetitive motion and on flare-ups. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. During the course of an appeal, a veteran may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). Therefore, the following analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Board finds that the preponderance of the evidence is against a rating higher than 40 percent for the Veteran’s lumbar spine disability. By way of background, the Veteran’s service-connected lumbar spine disability was assigned a 10 percent rating effective March 19, 1981, and a 40 percent, effective March 30, 1998. The current appeal period before the Board begins on February 9, 2011, the date VA received the Veteran’s claim for an increased rating, plus the one-year ”look back” period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). As a part of his application for a higher rating, the Veteran was afforded a VA examination in May 2011. On examination, the Veteran’s lumbar spine was limited in forward flexion to 40 degrees. There was no evidence of thoracolumbar spine ankylosis. The June 2011 rating decision determined that even though the examination showed some improvement in the condition, sustained improvement had not been definitely established and continued the 40 percent rating. Subsequently, the Veteran was afforded VA examinations in January 2019 and September 2019. The January 2019 VA examination report shows the Veteran complained of flare-ups and functional loss. On examination, forward flexion of the lumbar spine was limited to 60 degrees. There was no evidence of ankylosis of the spine. There was no pain noted on examination or with weightbearing. There was no objective evidence of localized tenderness or pain on palpation of the joints or associated soft tissue. He was able to perform repetitive use testing, but there was no additional loss of function or range of motion after three repetitions. There was evidence of pain on passive range of motion testing, but no evidence of pain when the joint was used in non-weight-bearing. There was no evidence of muscle spasm or guarding. Muscle strength and testing were normal. On sensory exam, he had mild intermittent pain in the right lower extremity, involving the L2/L3/L4 nerve roots. While it was noted that the Veteran had IVDS, he did not have any acute episodes or signs or symptoms due to IVDS that required bed rest within the past 12 months. He reported he did not use any assistive devices as a normal mode of locomotion. Pertinently, the examiner opined the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time or during flare-ups. She stated she was unable to opine whether pain, weakness, fatiguability, or incoordination significantly limited his functional ability with repeated use over a period of time or during flare-ups without mere speculation. In March 2019, VA obtained an addendum opinion to clarify if there was any additional loss of function upon repetitive use or during flare-ups. The examiner opined that after listening to his complete history and current subjective complaints, combined with a review of the available records, she had no basis to offer additional losses of function or motion. VA afforded the Veteran another VA examination in September 2019. The VA examination report shows the Veteran’s lumbar spine had forward flexion to 30 degrees. The Veteran’s range of motion contributed to functional loss in that he was unable to lift objects off the floor or get off the floor without assistance. Pain was also noted on examination was causing functional loss. There was evidence of pain on weightbearing. On observed repetitive use testing, the Veteran’s lumbar spine had forward flexion to 15 degrees. The Veteran reported pain, fatigue, weakness and lack of endurance contributed to his functional loss and that they significantly limited his functional ability with repeated use of his lumbar spine over time. On repeated use over time, forward flexion was to 15 degrees. While there was evidence of muscle spasm on examination, it did not result in abnormal gait or abnormal spinal contour. Muscle strength, reflex, and sensory testing were normal. Straight leg testing was normal and there was no evidence of radiculopathy. There was no evidence of ankylosis. There was no evidence of any other neurologic abnormalities or intervertebral disc syndrome (IVDS). He denied using an assistive device. He denied experiencing flare-ups. Collectively, the evidence does not demonstrate unfavorable ankylosis of the thoracolumbar spine, and therefore, the Board finds that an increased rating on this basis is not warranted. Under the rating criteria, a higher disability evaluation of 50 percent is warranted when there is evidence of unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a (2016). VA and private treatment records, as well as the January 2019 and September 2019 VA examinations, show the Veteran’s lumbar spine disability has been manifested primarily in limited range of motion of forward flexion to less than 30 degrees. Such findings are contemplated by the Veteran’s current 40 percent evaluation. In order to obtain a higher rating, the appellant would have to demonstrate ankylosis. To date, however, he has not done so. Indeed, during the January 2019 and September 2019 VA examinations, the examiner indicated, specifically, that ankylosis was not present. Absent evidence of ankylosis, the appellant does not meet or more nearly approximate the schedular criteria for a rating in excess of 40 percent. Moreover, without a finding of ankylosis, any additional functional loss during flare-ups or repeated use over time would not result in a higher rating. Since the Veteran has been granted the maximum rating possible under limitation of motion for the lumbar spine under the rating criteria, a further analysis under DeLuca, supra, would not result in a higher schedular rating. Johnston v. Brown, 10 Vet. App. 80, 85 (1995). Again, the evidence does not include any reports of ankylosis of the lumbar spine. The next-higher disability evaluation of 50 percent is warranted when there is total fixation of the spine in flexion or extension. 38 C.F.R. § 4.71a. While the Veteran experiences pain due to his spine disability, he has maintained some degree of motion despite his functional loss. Therefore, a higher disability evaluation based on functional impairment is not warranted. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, weakened movement, excess fatigability, incoordination, repetitive use, pain during flare-ups, and pain during repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in symptoms more nearly approximating unfavorable ankylosis of the entire thoracolumbar spine or entire spine generally. The Veteran’s symptoms do not more nearly approximate the entire spine fixed in flexion or extension and one of the additional symptoms set forth in Note 5. There is no indication that the Veteran had difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching.” Id. at Note 5. Additionally, there was no evidence of fixation of a spinal segment in neutral position (zero degrees). Rather, the Veteran’s forward flexion achieved 15 degrees. Further, in this case, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran’s descriptions of symptoms. The lay evidence has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating during the appellate period. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Rather, the September 2019 VA examiner noted he did not have any acute episodes or signs or symptoms due to IVDS that required bed rest within the past 12 months. Regarding associated neurological abnormalities, the Veteran is already service connected for radiculopathy of the right lower extremity and there is no indication that he sought a higher rating nor that he would be entitled to a higher rating. On the January 2019 examination, the Veteran was noted to have mild radiculopathy of the right lower extremity, which is contemplated by the Veterans current 10 percent rating. The September 2019 examination indicates there were no signs of radiculopathy of the lower extremities on examination. See 38 C.F.R. § 4.124A, DC 8526. The most recent examiner also found that the Veteran did not have any other neurological abnormalities associated with the lumbar spine. In sum, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his lumbar spine disability. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a higher than 40 percent for his service-connected lumbar spine disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7.   2. A rating higher than 20 percent prior to September 7, 2019, and a rating higher than 30 percent thereafter for a cervical spine The Veteran contends that he is entitled to a 50 percent rating for his service-connected cervical spine disability. See VA 21-526b, Veteran Supplemental Claim (February 2011). The Veteran’s cervical spine disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242, which is evaluated under the General rating Formula for Diseases and Injuries of the Spine. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Ankylosis is defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. When resolving the benefit of the doubt in favor of the Veteran, the Board finds that a 30 percent rating, but no higher, is warranted throughout the course of the appeal. By way of background, at the time of application for a higher rating, the Veteran was assigned a 20 percent rating from June 4, 2007. The current appeal period before the Board begins on February 9, 2011, the date VA received the Veteran’s claim for an increased rating, plus the one-year ”look back” period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). As a part of his application for a higher rating, the Veteran was afforded a VA examination in May 2011. The May 2011 VA examination report showed there was no evidence of ankylosis on examination. However, flexion was to 20 degrees, but the examiner did not opine about the amount of functional impairment in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups. See Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). As a result, the claim for a higher rating was denied in the June 2011 rating decision. December 2011 VA medical records show the Veteran underwent surgery for his cervical spine disability, a C4-5, C5-6, C6-7 anterior cervical diskectomy and arthrodesis with cervical plating and allograft. As a result, in a May 2012 rating decision, VA assigned the Veteran a temporary total evaluation (100 percent) due to his cervical spine disability necessitating a period of convalescence from December 23, 2011 to April 1, 2012, with a 20 percent rating from April 1, 2012 thereafter. The Veteran was afforded VA examinations in January 2019 and September 2019. In the January 2019 VA examination report, the Veteran reported experiencing flare-ups occurring 2-3 times per months for 3-4 days, relieved by hot showers or rest. On examination, range of motion testing revealed forward flexion to 20 degrees. Pain was noted as causing functional loss. He was able to perform repetitive use testing with at least three repetitions, but no additional loss of function or range of motion occurred. There was pain on passive range of motion, but no pain when the joint was used in non-weight bearing. While there was evidence of muscle spasm and guarding, it did not result in abnormal gait or abnormal spinal contour. Muscle strength, reflex and sensory testing were normal. There was no evidence of radiculopathy or any other neurologic abnormality. There was no evidence of ankylosis or IVDS. He did not use an assistive device to ambulate. Pertinently, the examiner noted that the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. She also stated that she could not provide an opinion on whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period or to express in terms of the degrees of additional range of motion loss due to pain on repetitive use or during flare-ups without resorting to speculation. As a result, in March 2019, VA obtained an addendum opinion to clarify if there was any additional loss of function upon repetitive use or during flare-ups. The examiner stated she documented the Veteran’s flare-ups in his own words, but it was not possible to determine and/or estimate loss of range of motion during flare-ups, or when the joint is used repeatedly over a period of time, and to describe any such additional limitation due to pain, weakness, fatigability or incoordination, as well as to express in terms of the degrees of additional range of motion loss due to pain, as there was no conceptual or empirical basis for making such determination without directly observing function under those conditions. As such, the January 2019 VA examination with March 2019 VA opinion also do not comply with the requirements under Sharp, cited above. Subsequently, VA afforded the Veteran a new examination with a different examiner in September 2019. The VA examination report shows the Veteran did not report flare-ups but reported having functional loss, stating that he had pain 100 percent of the time, sometimes were better than other times. He could not walk or stand or a long period, sit or lift heavy objects, and that it was hard to concentrate or get things done because it gave him headaches with nausea. On examination, forward flexion was to 10 degrees. Pain was noted on exam, but it did not result functional loss. There was localized tenderness or pain on palpation of to the paracervical of moderate severity. There was pain with weight-bearing as well. Repetitive use testing showed limitation in forward flexion to 5 degrees. The examiner noted that pain, fatigue, weakness and lack of endurance significantly limited his functional ability with repeated use over time but was still limited to 5 degrees. He had muscle spasm on examination that resulted in abnormal gait or spine contour. Muscle strength, reflex and sensory testing were all normal. There were no signs of radiculopathy. There was no evidence of ankylosis, IVDS or neurologic abnormalities related to the cervical spine. The Veteran did not use an assistive device to ambulate. The examiner noted there was objective evidence of pain when the neck was used in non-weight bearing; however, passive range of motion for the neck could not be performed or was not medically appropriate. The examiner noted the examination was medically consistent with the Veterans’ statements describing functional loss with repetitive use over time. Initially, the Board finds that when resolving the benefit of the doubt in favor of the Veteran, a 30 percent rating is warranted for his cervical spine disability throughout the course of the appeal from the date of claim for an increased rating, February 9, 2011. In this regard, as discussed above, the prior examinations in May 2011 and January 2019 with the March 2019 addendum opinion are inadequate under Sharp, cited above. In this regard, neither examiner adequately addressed any additional loss in degrees during flare-ups or following repetitive use over time. Accordingly, the Board finds that based on the findings at the September 2019 VA examination, which showed limitation to 5 degrees following repeated use over, a 30 percent rating is warranted throughout the course of appeal. The Board finds that the appropriate effective date is the February 9, 2011 date of claim as there is no evidence within one year prior showing that a higher rating is warranted. However, a rating higher than 30 percent rating is not warranted. The September 2019 VA examination shows forward flexion to 5 degrees at its most restrictive following repeated use, which is contemplated by the Veteran’s currently assigned 30 percent rating. There is no evidence of record during the appellate period that the Veteran had unfavorable ankylosis of the entire cervical spine or unfavorable ankylosis of the entire spine to warrant a 50 or 100 percent rating. Moreover, without a finding of ankylosis, any additional functional loss during flare-ups or repeated use over time would not result in a higher rating. Since the Veteran has been granted the maximum rating possible under limitation of motion for the cervical spine under the rating criteria, a further analysis under DeLuca, supra, would not result in a higher schedular rating. Johnston v. Brown, 10 Vet. App. 80, 85 (1995). Again, the evidence does not include any reports of ankylosis of the cervical spine. The next-higher disability evaluation of 40 percent is warranted when there is unfavorable ankylosis of the entire cervical spine. 38 C.F.R. § 4.71a. While the Veteran experiences pain due to his spine disability, he has maintained some degree of motion despite his functional loss. Therefore, a higher disability evaluation based on functional impairment is not warranted. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to include causes of additional functional loss (pain, weakened movement, excess fatigability, incoordination, repetitive use, pain during flare-ups, and pain during repetitive use over time). However, in this case, the competent medical evidence offering detailed specific specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran’s descriptions of symptoms. The lay evidence has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. The Board specifically considered the lay evidence is awarding the current 30 percent rating from the date of claim. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS of the cervical spine and the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. The Board also notes with the exception of the already service-connected headaches, there is no evidence of any other neurologic impairment caused by the Veteran’s service-connected cervical spine disability. Further, the Veteran has already been granted service connection for migraine headaches at 50 percent effective September 7, 2019, which is the maximum schedular rating available pursuant to VA regulations. See 38 C.F.R. § 4.124A, DC 8100. The Veteran has not raised entitlement to a higher rating, an extraschedular rating, for migraine headaches nor was it reasonably raised by the record. Thun v. Peake, 22 Vet. App. 111 (2008); Barringer v. Peake, 22 Vet. App. 242 (2008). Moreover, the most recent VA examiner clearly found that the Veteran did not suffer from any other neurologic abnormalities associated with the cervical spine. For the foregoing reasons, when resolving the benefit of the doubt, a 30 percent rating, but no higher, for cervical spine disability is warranted from February 9, 2011. However, the preponderance of the evidence is against the Veteran’s claim for a rating higher than 30 percent at any point during the course of the appeal. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. J.N. MOATS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Pendleton, N. 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.