Citation Nr: 21026440 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 16-52 029 DATE: May 3, 2021 REMANDED Service connection for residuals of a traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served on active duty in the Marine Corps from July 1964 to January 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In August 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a video-conference hearing. A transcript of that hearing is of record. In February 2020 and December 2020, the Board remanded the claim to the RO for additional development. Service connection for residuals of a TBI is remanded. While on remand, an addendum opinion was obtained in February 2021. The examiner provided a negative opinion. For their rationale, the examiner notes the Veteran was shown to have hit his head in October 1964 while jumping on a trampoline and that he was treated for a neck, not a head injury. In February 1965, the examiner observes the Veteran was treated for a scalp laceration and found there was no mention of a TBI or concussion symptoms. The examiner notes they found no evidence of a truck accident, and since they found no evidence in the Veteran's service medical records to support the presence of an in-service TBI, they conclude there remains no diagnosis of a TBI. The Board finds the February 2021 examiner's negative opinion to be insufficient. First, the examiner determined there is no evidence of a truck accident. However, as stated in the Board's prior remand instructions, the Veteran asserts he suffered a head injury during service when he was thrown from a truck and landed on his back. While he did not lose consciousness, the Veteran reported suffering from headaches and back pain a few days later. He has stated he did not report the incident because he did not want the driver of the truck to get in trouble. While there is no evidence documenting the specific incident, there is evidence that supports the Veteran's assertions. For example, his service treatment records do show he was seen for a dressing change on February 2, 1965, and for a back and check of a scalp laceration on February 5, 1965. This documentation supports the Veteran's assertions. As a result, the Board has no reason to doubt the Veteran's claim that he was in a truck accident during active service, and he is competent to report such and any symptoms or treatment he received after the reported the accident. Furthermore, while the examiner concluded there is no evidence to support the presence of an in-service TBI, they did not address the post-service July 2015 MRI results or the August 2019 letter from G.S., NP, finding the Veteran had abnormalities on MRI scan of his brain from February 2019 that were documented as being "potentially secondary to head trauma" and/or an autoimmune disorder. Additionally, while the examiner states the Veteran was treated for a neck, not a head injury after he hit his head in October 1964 while jumping on a trampoline, the service medical records from October 31, 1964, state the Veteran fell on his head, and on November 6, 1964, it was documented, "he continues to have headaches." It seems the examiner is concluding the Veteran did not suffer any head trauma after his trampoline accident because "the Veteran was treated for a neck, not a head injury." However, the Veteran's service medical records clearly show the Veteran was treated for both a neck and a head injury. As such, the Board cannot accept the examiner's finding that the Veteran was treated for a neck and not a head injury. Finally, while the examiner did not find a TBI, they did not address the Board's question as to whether it is at least as likely as not the Veteran has any current residuals of his in-service head injuries. Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the Board confers the right to compliance with remand orders). As a result, a remand is required for VA to obtain an adequate opinion as to the etiology of any diagnosed TBI. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records, dated from February 2021 forward. 2. Request a VA examiner, if possible other than examiner who provided the February 2021 opinion, review the electronic file and provide an addendum medical opinion. If the VA examiner determines that an additional examination (or telehealth interview) of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled; however, the Veteran should not be required to report for another examination (or telehealth interview) as a matter of course, if it is not found to be necessary. (a.) The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) the Veteran has any current residuals of his in-service head injuries. (b.) The examiner should specifically provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) the Veteran's headaches, loss of balance, subarachnoid cyst, neurosarcoidosis, smooth dural enhancement of supra-tentorial and infra-tentorial spaces, and/or abnormalities shown on the brain MRI scan from February 2019 were caused by his in-service head injuries. In providing the above opinion(s), the examiner should specifically consider the following: The service treatment record showing the Veteran was seen in the emergency room following an automobile accident on April 6, 1964, and the accompanying skull x-ray. The service treatment record showing the Veteran was seen in the emergency room on October 31, 1964, after suffering a head injury while jumping on a trampoline; The service treatment record dated November 6, 1964, noting the Veteran continued to have headaches; The Veteran's assertion he suffered a head injury during service when he was thrown from a truck and landed on his back; while he did not lose consciousness, he reportedly suffered from headaches and back pain a few days later; he did not report this incident because he did not want to get the driver of the truck in trouble; however, his service treatment records do show he was seen for a dressing change on February 2, 1965, and for a back and check of a scalp laceration on February 5, 1965; The post-service July 2015 MRI showing status post sub-occipital craniotomy with large posterior arachnoid cyst, shunt noted, extensive smooth dural enhancement of supra-tentorial and infra-tentorial spaces, "ddx" prior hemorrhage versus inflammatory meningitis, post-trauma or "post-inflma" favored. The examiner noted the Veteran's headaches were better, and his balance was a touch worse; and The August 2019 letter from G.S., NP, finding the Veteran had some abnormalities on his brain MRI scan from February 2019 that were nonspecific but were "potentially secondary to head trauma" and/or an autoimmune disorder. (Continued on the next page) A complete rationale for all opinions expressed should be set forth in the examination report. P. M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Denton, Buck 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.