Citation Nr: 21030873 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 17-59 400 DATE: May 19, 2021 ORDER Service connection for thoracic syringomyelia, status post laminectomy with excision of calcified fleshy intradural extra axial lesion with duraplasty with scar and left foot weakness (claimed as a back condition), is granted. REMANDED Service connection for erectile dysfunction, to include as secondary to back condition, is remanded. Service connection for bilateral ankle condition is remanded. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, syringomyelia with complaints of functional paraparesis with subjective decreased sensation is the result of an in-service injury (i.e., parachute jump(s)). CONCLUSION OF LAW The criteria for service connection for thoracic syringomyelia are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from November 1971 to October 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2016 and September 2018 rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO). In February 2021, the Veteran testified in a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is included in the record and has been reviewed. 1. Service connection for thoracic syringomyelia, status post laminectomy with excision of calcified fleshy intradural extra axial lesion with duraplasty with scar and left foot weakness also claimed as a back condition The Veteran contends he is entitled to service connection for his back condition. The VA examination of record establishes that the Veteran has a current disability of thoracic laminectomy with the excision of calcified fleshy intradural extra axial lesion with duraplasty with scar and left foot weakness secondary to thoracic syringomyelia. See October 2015 Back Condition VA Examination. The October 2015 VA examiner opined that it is less likely than not that the Veteran's back condition was incurred in or caused by the claimed in-service injury, event, or illness. The examiner in rendering his or her opinion failed to consider the Veteran's multiple complaints of back pain found in his service treatment records, including in 1984, 1987, and on discharge in 1997. Additionally, the examiner rendered his or her opinion based on the belief that the Veteran served from 1977 to 1995. While the Board acknowledges the Veteran's DD-214 is confusing, the Board notes that the Veteran served in the United States Army from November 1, 1971 to October 31, 1995. See DD-214 Form. The Veteran testified before the undersigned that he did not have back problems prior to military service but began to experience back problems after parachute jumps while in the military. He testified that the symptomology continued until the present day. The undersigned found the Veteran's testimony to credible. The Veteran provided three medical opinions from his private treating physicians, Dr. E.H., Dr. R.G., and Dr. J.G. Dr. E.H. submitted a February 2016 opinion stating that the Veteran was a patient under his care for evaluation of a thoracic myelopathy resulting from syringomyelia. See Medical Treatment Records. The clinician noted that the Veteran hurt his back while parachuting in service and detailed the Veteran's reports of symptoms. In 1988, the Veteran started stubbing the toes on the left side and developed numbness of the left leg and foot. By 1992, the numbness had spread to both of the Veterans' legs and he experienced loss of mobility in 1996. The examiner indicated that he or she first evaluated the patient in October 2007 and that the cause of syringomyelia is often unknown. The clinician included a letter to the editor of the New England Journal of Medicine in 2003 that detailed two patients who developed syringomyelia while skydiving. Taken altogether, the clinician opined that the patient's condition is the result of multiple parachuting jumps. Dr. R.G. also completed and submitted an opinion in June 2019. See Medical Treatment Records. The clinician indicated that the Veteran had been a patient under his care for his thoracic syringomyelia and associated myelopathy since April 2016. The examiner contended that the Veteran's condition stems from injury suffered while on active duty in the U.S. Army from 1981 to 1995. Specifically, the examiner stated the Veteran suffered a fall onto his upper back causing a hyperflexion injury while involved in parachute training in 1973. The examiner further opined that the injury the Veteran incurred has been well described in the medical literature as being associated with his mechanism of injury. The third opinion submitted was completed by Dr. J.G. in November 2019. See Medical Treatment Records. Dr. J.G. stated that he is a board-certified neurosurgeon who the Veteran saw between February 2019 and October 2019. The clinician indicated that the Veteran was injured in a parachute accident in 1973 resulting in transient paraparesis. The Veteran subsequently worsened significantly in 1988. The clinician indicated that syringomyelia is due to traumatic injury. Given that the Veteran's symptoms began immediately after a parachute injury while in service, the clinician opined that it could be concluded to a reasonable degree of medical certainty that the Veteran's in-service injury is directly related to his service activity, including his parachute activity and accidents. Review of the medical records confirms that the Veteran received treatment on several occasions due to back pain. Upon review of the record, the Board finds the probative evidence supports finding that the Veteran's back condition is due to his in-service parachute activity and accidents. The October 2015 VA examiner relied on the absence of and failed to review the entire record prior to rendering his or her opinion. See Fountain v. McDonald, 27 Vet. App. 258, 272-75 (2015) (indicating that a VA examiner may not generally rely on the absence of evidence as negative evidence). As such, the Board gives this opinion limited weight. Conversely, the private opinions submitted by the Veteran. receive significant weight as they are consistent with the medical and lay evidence of record. Dr. E.H., Dr. R.G., and Dr. J.G. all note and opine that the Veteran's injury is the result of his in-service parachute activities and accidents. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). REASONS FOR REMAND 2. Service connection for erectile dysfunction, to include as secondary to back condition, is remanded. The Veteran contends he is entitled to service connection for his erectile dysfunction, to include as secondary to his back condition. See February 2021 Hearing Transcript. The Veteran has not been afforded a VA examination for his erectile dysfunction for either direct or secondary service connection. In light of the positive evidence provided by the Veteran and the Board's grant of service connection for the Veteran's back condition (the disorder underlying part of the Veteran's theory of secondary service connection), the Board finds such examination is warranted. See McClendon v. Nicholson, 20 Vet. App. 79, 81 (2006) (describing the circumstances under which VA's duty to provide a medical examination are triggered). At the 2021 hearing, the Veteran's representative alleged the Veteran has erectile dysfunction secondary to his back condition, thoracic syringomyelia. An opinion addressing this allegation should be obtained. See February 2021 Board Hearing. Specifically, the Veteran indicated that his back condition causes him not to feel his lower extremities, which causes him to wet the bed. These competent observations must be addressed in any etiology opinion. Service connection for bilateral ankle condition is remanded. The Veteran contends he is entitled to service connection for his bilateral ankle condition. See February 2021 Hearing Transcript. In October 2015, an opinion for the Veteran's ankle condition was completed. The examiner opined that there is no diagnosis for the Veteran's left or right ankle conditions because there is no pathology to render a diagnosis. See October 2015 Ankle VA Opinion. Further, the examiner opined that the Veteran "does not have an[n] ankle condition it's more often nerve, none of it found in during the service." Once VA undertakes the effort to provide an examination, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311. The Veteran's STRs include notes of ankle pain during service. In June 1972 there is a medical note of pain in the Veteran's left ankle. See June 1972 STRs. Additionally, in February of 1984 the Veteran sought treatment for a right ankle sprain following a fall. See February 1984 STRs. As these notations are related to the Veteran's bilateral ankle condition and were not considered by the examiner in rendering his or her opinion, the Board finds the October 2015 opinion to be inadequate. Based on the examiner's failure to consider and address the Veteran's STRs noting ankle problems and to address the lay reports of ankle symptomology, the Board must remand this matter for an addendum VA medical opinion that addresses all the evidence of record. Any etiology opinion must take into account the Veteran's credible medical history. Therefore, a remand is necessary for an addendum opinion to discuss the nature and etiology of the Veteran's bilateral ankle condition. The matters are REMANDED for the following action: 1. Obtain updated VA and/or identified pertinent private treatment records to the extent possible. If such records are unavailable, the Veteran's claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Obtain a medical examination to determine the nature and etiology of the Veteran's erectile dysfunction from a medical professional with appropriate expertise. The examiner should review the Veteran's claims file, including a copy of this remand. An examination of the Veteran should only be scheduled if the examiner determines this is necessary to provide the requested opinions.Based on a review of the record and an examination, the examiner must address the following: (a.) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's erectile dysfunction is related to his active service or is caused by or aggravated by military service. (b.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that erectile dysfunction is proximately due to or the result of the Veteran's service-connected disabilities and/or the medications taken for the Veteran's service connected disabilities? (c.) If the answer to (b) is negative, is it at least as likely as not that erectile dysfunction is aggravated (i.e., permanently or temporarily worsened) by the Veteran's service-connected disabilities? (d.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms and treatment history related to erectile dysfunction from in-service to the present. 3. Return the claims file to the examiner who conducted the 2015 VA ankle examination and request they prepare an addendum examination report which addresses the following question. The Veteran should only be scheduled for further examination if the examiner determines this is required in order to provide the requested opinions. If the examiner who conducted the 2015 VA ankle examination is unavailable, arrange to obtain the addendum opinion from another suitably qualified health care professional. A complete copy of the record must be provided to the examiner, including a copy of this remand. The examiner must consider lay reports of observable symptomatology. After a thorough review of the record, the examiner should respond to the following: Is it at least as likely as not (i.e. a probability of 50 percent or more) that the Veteran's bilateral ankle condition had its onset during active service or within one year of separation from service, or, otherwise resulted from active military service? The opinion must reflect consideration of the Veteran's in-service and post-service reports of bilateral ankle pain. The examiner should provide a complete rationale explaining the medical reasons for all opinions provided. If an opinion cannot be provided without resorting to mere speculation, the examiner should fully explain why he or she cannot provide the requested opinion and identify what additional evidence (if any) would make it possible to provide a more definitive opinion. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms and treatment history related to bilateral ankle pain from in-service to the present. The examiner should consider and address the Veteran's testimony and lay statements of record. If there is a medical basis to support or doubt the history provided, the examiner should provide a fully reasoned explanation. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. The term "aggravation" means a permanent increase in the claimed disability; that is, an irreversible worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). (Continued on the next page) (Continued on the next page) G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board V. Schmidt 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.