Citation Nr: 21028026 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 15-35 680 DATE: May 10, 2021 REMANDED Entitlement to service connection for a cervical spine disorder is remanded. Entitlement to service connection for a left hip disorder is remanded. REASONS FOR REMAND The Veteran had active duty with the United States Navy Reserve from August 26, 1991 to September 6, 1991, from May 1, 1996 to September 30, 1996, from November 12, 1996 to February 15, 1997, from August 12, 1998 to September 2, 1999 and from February 24, 2003 to July 31, 2003. A Travel Board hearing was held in August 2016 and a transcript is of record. In December 2018 the Board remanded the issues on appeal as well as the claim of entitlement to service connection for a left foot arch disorder. Subsequently, the Agency of Original Jurisdiction in a June 2020 rating decision granted service connection for left foot pes planus (left foot arch condition), which is a full grant of the benefit sought and the issue is no longer in appellate status. Issues 1-2: Entitlement to service connection for a cervical spine disorder and a left hip disorder. In the December 2018 remand, the Board instructed that the Veteran be afforded a VA examination to determine the nature and etiology of his cervical spondylosis and that the examiner discuss the likelihood that cervical spondylosis resulted from the documented in-service injury. The Board noted in the remand that during the August 2016 Board hearing, the Veteran testified that he sustained a severe blow to the head while playing basketball during a period of annual training in September 1991. He lost consciousness and received sutures for a gash in his head at St Joseph's Hospital and returned to the Reserve Center. Service treatment records confirm that on September 4, 1991, the Veteran was treated for a laceration above the right eye when his eyeglasses were broken while playing basketball. He was transported to a private facility for further care. Another entry shows that the Veteran's sutures were removed on September 8. The wound was clean with no sign of infection and healing well. As the Veteran contends through his representative in the April 2021 brief, the VA examiner who rendered the December 2019 opinion did not comply with the Board's remand directives. In the December 2019 opinion the VA examiner opined that the Veteran's cervical spine disability was less likely than not incurred or caused by service as there was no spondylosis in service and no evidence in the service treatment records of a neck injury or head trauma. However, as discussed above in the December 2018 remand the Board instructed the VA examiner to discuss the likelihood that cervical spondylosis resulted from the documented in-service injury whereby the Veteran in September 1991 was treated for a laceration above the right eye. Therefore, there is a lack of compliance with the Board's remand directives. Compliance with the Board's remand instructions is neither optional nor discretionary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). As for the left hip disorder, the Veteran contends that it is due to his cervical spondylosis. However, because the development and outcome of the pending cervical spine claim may impact the left hip claim, they are inextricably intertwined. Harris v. Derwinski, 1 Vet. App. 180, 183 (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a veteran's claim for the second issue). Thus, adjudication of the claim must be deferred until after completion of the actions requested below. The matters are REMANDED for the following action: 1. With any necessary assistance from the Veteran, obtain any outstanding medical records. All attempts associated therewith should be memorialized in the Veteran's claims file. 2. Afterwards obtain an addendum opinion from the examiner who rendered the December 2019 VA opinion regarding the nature and etiology of the Veteran's cervical spine disorder. If the examiner is unavailable another competent examiner should render the opinion. The electronic claims file should be made available for review to the examiner to include a copy of this remand. The examiner must explain the underlying rationale for all opinions expressed. If the examiner cannot render an opinion without resorting to mere speculation, a full and complete explanation for why an opinion cannot be rendered should be provided. If necessary, the Veteran should be scheduled for a VA examination. a.) With respect to the cervical spine disorder: The examiner should provide an opinion regarding whether the Veteran has a cervical spine disorder that at least as likely as not, (i.e., a 50 percent probability or greater) had its clinical onset during, or is otherwise associated with, his service. The examiner is asked to discuss the likelihood that a cervical spine disorder would have resulted from the documented in-service injury whereby on September 4, 1991, the Veteran was treated for a laceration above the right eye when his eyeglasses were broken while playing basketball. He was transported to a private facility for further care. Another entry shows that the Veteran's sutures were removed on September 8. The examiner is hereby advised that the Veteran testified in August 2016 that he sustained a severe blow to the head while playing basketball during a period of annual training in September 1991. He lost consciousness and received sutures for a gash in his head at St Joseph's Hospital and returned to the Reserve Center. The examiner also is advised that on VA examination in December 2019, the diagnoses were spinal stenosis, cervical fusion and laminectomy, incomplete tetraplegia due to spinal stenosis, and degenerative joint disease. b.) With respect to the left hip disorder: The examiner should provide an opinion whether the Veteran has a left hip disorder which is at least as likely as not, (i.e., a 50 percent probability or greater) caused by his cervical spine disorder, to include cervical spondylosis, or is aggravated by a cervical spine disorder, to include cervical spondylosis. The examiner is hereby advised that on VA left hip examination in December 2019, the diagnosis was arthritis of the left hip and partial tetraplegia due to neck stenosis. Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Mac, 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.