Citation Nr: 21026220 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 03-32 125 DATE: April 30, 2021 ORDER Service connection for an unidentified right upper extremity (RUE) condition as secondary to service-connected cervical spine disability is denied. FINDINGS OF FACT 1. The Veteran has an undiagnosed RUE condition manifested by pain, weakness, and spasms that impairs his earning capacity. 2. The Veteran is currently service connected for degenerative disc disease of the cervical spine. 3. The undiagnosed RUE condition is not caused by, or increased in severity beyond the natural progress of the disease by, any service-connected disability, to include degenerative disc disease of the cervical spine. CONCLUSION OF LAW The criteria for service connection for an undiagnosed RUE disorder as secondary to service-connected cervical spine disability have not been met. 38 U.S.C. §§ 1110, 1154, 5103, 5013A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty in the Navy during the Vietnam Era from July 1970 to May 1974. Service Connection for RUE Condition is Denied. Service connection may be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See id.; Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). The Veteran first brought a claim for impairment of the RUE, secondary to service-connected neck disability, in February 2013. The Veteran most recently contends that he has a RUE radiculopathy that he believes is caused by the service-connected cervical spine disability. See, e.g., March 2021 Statement of Veteran’s Representative. The Veteran is currently service connected for degenerative disc disease of the cervical spine. In a March 2021 brief, the Veteran’s representative argued that the most recent VA examinations have not conclusively ruled out cervical complications as a cause of the Veteran’s current RUE symptoms. The representative’s contention was that, if the record is inconclusive on a particular medical question, it should be an open question and, therefore, 50-50 as to whether RUE weakness and pain is service connected, and, with the evidence in equipoise, the claim should be granted. The weight of the evidence shows that the Veteran has an undiagnosed disability manifested by pain, weakness, and spasms in the RUE that impairs his earning capacity. Under Diagnostic Code 8710, neuralgia of the fifth and sixth cervicals, a disability is manifested where there is dull and intermittent pain in the extremity. The treatment records indicate similar symptoms. See Saunders v. Wilkie, 886 F.3d 1356 (2018) (holding that symptoms of pain, without a clinical diagnosis, that result in functional impairment causing decreased earning capacity, will be considered a disability). The evidence in this case includes multiple examination reports, diagnoses, and medical opinions. A VA examination in February 2013 revealed that the Veteran did not have any radicular pain or any other signs or symptoms of radiculopathy in the lumbar or cervical spine. VA treatment records from February 2013 show that the Veteran complained of weakness in the right hand, right wrist pain, and a periodic paralyzed sensation in the thumb and index finger of the right hand. The impression was either carpal tunnel syndrome or thoracic outlet syndrome. VA performed an MRI of the cervical spine in March 2013 in response to Veteran’s claims of neck pain and RUE pain and weakness. The examiner noted mild to moderate degrees of foraminal narrowing at C4/5 and C5/6, but otherwise no significant spinal canal or foraminal stenosis. In 2014, the Veteran began complaining of tremors and spasms, especially in the upper extremities. These symptoms were in addition to weakness of the RUE. VA treatment records from June 2014 indicate that the tremors were non-physiologic. Another VA examination in July 2014 found no radicular pain or any other signs or symptoms of radiculopathy in the lumbar or cervical spine, and no significant neurological issues. The examiner did note the mild to moderate foraminal narrowing at C4/5 and C5/6 found in the March 2013 MRI, but still found no signs or symptoms of radiculopathy. The Veteran received an EMG (electromyogram) in August 2014. The impression from the EMG was that there was no evidence of neuropathy or cervical radiculopathy causing symptoms in the RUE. VA treatment records from October 2014 noted that the Veteran received an EMG, the results of which were negative for any neuropathy. While the EMG did not confirm a radiculopathy, the EMG did not rule out one. VA treatment records from September and December 2014 include an impression that the Veteran has myofascial pain syndrome and chronic spasms of the right lavator scapulae and trapezius muscles. In December, the examining physician noted that the symptoms do not appear to be related to an underlying cervical radiculopathy. Private treatment records from January 2015 note that the tremors in the RUE were consistent with psychogenic factors, rather than physiological ones. VA treatment records from May 2015 note that the consensus at the time as to the Veteran’s symptoms are that he has myofascial pain syndrome, myoclonus of idiopathic origin, and cervicobrachial compression syndrome. All of which contribute to the right arm weakness, pain, and tremors. Treatment in July 2015 also noted cervicobrachial compression syndrome. The Veteran was examined by VA in January 2016. The examiner noted that the Veteran did not have any radicular pain or any other signs or symptoms due to radiculopathy. The examiner also noted no neurologic abnormalities related to the cervical spine. Private treatment records from April 2017 note that the private physician found that the numbness and weakness of the right hand were consistent with carpal tunnel syndrome and not with cervical disc disease. Another VA examination in August 2017 noted no radicular pain, signs or symptoms due to radiculopathy, or neurologic abnormalities related to the cervical spine. A VA opinion offered in October 2018 was that the Veteran suffered from an unknown central nervous system issue and cervical radiculopathy. VA treatment records from February 2018 note an impression of compression of the right cervicobrachial nerve. A VA examination in July 2019 noted no radicular pain, signs or symptoms due to radiculopathy, or neurologic abnormalities related to the cervical spine. A VA examination in October 2020 noted no radicular pain, any signs or symptoms due to radiculopathy, and no neurologic abnormalities related to the cervical spine. The examiner opined that the pain and spasms in the right arm do not appear to be due to cervical radiculopathy: the Veteran’s previous imaging, EMG and provider notes do not support a diagnosis of radiculopathy, as the Veteran’s neurologist stated in November 2014 that “the symptoms do not appear to be primarily related to an underlying cervical radiculopathy or facet mediated pain.” The examiner noted that the Veteran has mild degenerative changes of the cervical spine, as imaged in August 2017, which would not account for the current symptoms. The examiner pointed to EMT results from June 2017 which were minimally abnormal similar to 2013 which was read as normal, slight right ulnar nerve changes that do not explain radiating neck pain. Analysis After a review of all the evidence, lay and medical, the Board finds that the current undiagnosed RUE condition is not caused by, or increased in severity beyond the natural progression of the disease by, the degenerative disc disease of the cervical spine. The various diagnoses of record that account for the complaints and symptoms are cervicobrachial compression syndrome, carpal tunnel syndrome in the right wrist, and idiopathic or psychogenic pain and tremors in the right arm. VA treatment records note the arm pain and tremors as idiopathic. As idiopathic implies, the cause of the pain and tremors has not been determined. Dorland’s Illustrated Medical Dictionary at 912 (32nd ed. 2012) defines the term idiopathic as “of unknown cause or spontaneous origin.” Describing a term as idiopathic is commonly a diagnosis of exclusion: known causes of a condition are ruled out through testing, and once all known causes are eliminated, an idiopathic origin is used. See Tirlapur, Seema A et al. “How do we define the term idiopathic?” Current opinion in obstetrics & gynecology vol. 25,6 (2013): 468-73. Logically, a diagnosis of idiopathic origin means that other causes, in this case such as cervical radiculopathy, have been ruled out. See https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/radiculopathy (noting that cervical arthritis and similar disorders cause cervical radiculopathies, resulting in pain, weakness, and numbness in the upper extremities). As outlined above, in the record, multiple examiners have ruled out other causes, such as radiculopathies, for the pain and weakness. Consequently, a disorder of idiopathic origin implies that the cause of the symptoms is not a known cause like the cervical degenerative disc disease; thus, this diagnosis has no tendency to suggest that the idiopathic pain and weakness are secondary to the cervical spine disability. As noted above, a private physician noted the cause of the Veteran’s symptoms as psychogenic. Symptoms having a psychogenic origin, by definition, cannot be caused by the cervical spine disability. Merriam-Webster’s Medical Dictionary defines psychogenic as “originating in the mind; attributable to psychological or emotional factors.” By definition, symptoms originating from the mind are necessarily distinct from symptoms from a physical disability, namely, cervical spine disability. Such assessment that the symptoms are of psychogenic origin is evidence that weighs against the claim because it points to a mental origin that necessarily is not the physical cervical spine disability. Pain in the arm due to carpal tunnel syndrome also cannot be causally connected to the cervical spine because the diagnosis shows an anatomically remove origin of the symptoms far removed from the cervical spine, with no suggestion of cervical spine involvement. Merriam-Webster’s Medical Dictionary defines carpal tunnel syndrome as “a condition caused by compression of a nerve where it passes through the wrist into the hand.” Carpal tunnel syndrome stems from the wrist, which is anatomically remote from the neck or cervical spine. The anatomical remoteness and the established causation of nerve compression in the wrist weighs against degenerative disc disease of the spine as a cause of carpal tunnel syndrome. Cervicobrachial compression syndrome is one of a family of umbrella terms that are used as a diagnosis for a broad set of symptoms with unknown but estimated causes. The National Institutes of Health note that there is limited agreement between physicians on causes, symptoms, and even the validity of some of these related umbrella terms. The use in the record of the diagnosis is consistent with its use for symptoms resembling some kind of nerve disorder, but without a clear nervous cause. While a diagnosis of cervicobrachial compression syndrome suggests at best unknown causes of the symptoms, the weight of the evidence of record shows that the cause is not neurological. The record contains numerous imaging studies and electrical testing that was conducted to try to diagnose a nervous cause of the arm symptoms, with results negative for a nervous cause of the pain. Six VA examinations all stated that the Veteran did not have any signs or symptoms of a RUE radiculopathy. MRIs and EMGs performed in 2013 and 2014 found no evidence of a RUE radiculopathy. One VA examination stated that the Veteran had cervical radiculopathy. However, that opinion is outweighed by the six other VA examinations and the VA and private treatment records. Consequently, the diagnosis of cervicobrachial compression syndrome does not comport with a finding that the cervical spine disability and any possibly neurologic involvement caused the current reported upper extremity symptoms. Consequently, the Veteran does not have a current diagnosis of a disability, only symptoms of pain, weakness, and tremors. Considering the symptoms of pain, weakness, and tremors are functionally impairing, the Veteran has a current disability. The question then is whether the current disability of functionally impairing pain, weakness, and tremors is secondary to the service-connected degenerative disc disease of the cervical spine. On the question of secondary nexus, while a February 2021 nexus opinion was not able to absolutely rule out cervical complications as causing or aggravating the RUE symptoms, the examiner concluded that the bulk of the evidence went against finding a nexus between the RUE symptoms and the service-connected cervical spine disability. For the reasons described above, the Board finds that a preponderance of the lay and medical evidence is against the claim for service connection for an unidentified RUE condition manifesting in pain and weakness and resulting in functional impairment as secondary to service-connected cervical spine disability. For these reasons, the appeal must be denied. J. PARKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Charles Plambeck 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.