Citation Nr: 21030992 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 16-13 977 DATE: May 20, 2021 REMANDED Entitlement to service connection for an upper spine condition is remanded. Entitlement to service connection for radiculopathy of the bilateral upper extremities is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1983 to August 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In December 2018 the Board remanded the claims for updated VA examinations. As an initial matter, the Board notes that the Veteran's claim, as expressed at the August 2016 Board hearing, is for a disability of his neck and upper back ("from C7 to T3"), not his low back. Therefore, the claim for a spine condition has been restyled to clarify that the claim is for an upper spine condition. Unfortunately, the Board finds that an adequate examination was not provided following the Board's prior remand, and therefore further remand is required. At the August 2016 Board hearing, the Veteran testified that while performing his service occupational specialty as a mechanic, an unsecured 150-pound hook on a wrecker unraveled and fell directly on his upper back and shoulder blades. He stated that he sought treatment during service and was told it was a "strange sprain" that would resolve, and that he was put on light duty for a few weeks. Service treatment records also show the Veteran's upper back was injured when it was impacted by a rock doing sit-ups in bootcamp; at the Board hearing, the Veteran said he "didn't think that [injury] was of any significance . . . because it was sore a day or two and then I moved on." Eventually, the Veteran was medically discharged based on a medical board's diagnosis of "upper back pain, etiology undetermined." The Veteran related at the Board hearing that he had been privately encouraged not to continue seeking treatment in service or afterwards because it could disqualify him from staying in the military or reenlisting after his medical discharge. He testified that his upper back never healed and feels the same today as it has since service. The Board notes, as found in the prior December 2018 decision, that while the Veteran was in a motor vehicle accident prior to service, his entrance examination found his spine normal, and the Veteran testified at the Board hearing that it was his lower back, not any part of his upper back, that was injured in that accident. Thus, the Veteran is presumed to have been in sound health regarding his upper back at the time of induction to service. Following the Board's prior December 2018 decision, a new VA examination was provided in January 2020. After thorough review of the Veteran's service treatment records, the examiner opined that the "majority of evidence does not suggest a nexus" and that the "Veteran's current spine condition is more than likely due to spine spondylosis," which the examiner remarked "is a degenerative condition secondary to aging." The examiner's opinion, however, did not at all discuss the injury to the Veteran's neck when a 150-pound wrecker chain fell on his neck, nor did his opinion discuss why the Veteran's recorded injury from the rock during sit-ups could not have a relationship to the Veteran's current upper back condition. Because the examiner relied solely on objective medical evidence in the service treatment records to the exclusion of the Veteran's competent lay statements, and because the examiner failed to provide a complete medical rationale, the January 2020 opinion is inadequate, and a new examination must be provided. Dalton v. Nicholson, 21 Vet. App. 23, 39, 40 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). Regarding the Veteran's claim for radiculopathy of the bilateral upper extremities, a new opinion was provided in January 2020, with the examiner finding that the "Veteran['s] right cervical C7 radiculopathy . . . is related to the Veteran's cervical spine spondylosis." Thus, service connection for radiculopathy turns on whether service connection may be established for the Veteran's cervical spine condition. As entitlement to service connection for the upper spine condition is being remanded, entitlement to service connection for radiculopathy must be remanded with it. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the matters are REMANDED for the following action: 1. Schedule the Veteran for an examination regarding the etiology of his upper spine condition, including diagnosed spondylosis. The examiner must opine whether the upper spine condition is at least as likely as not related to the Veteran's service. The examiner must discuss the Veteran's in-service injuries including (i) an injury to the Veteran's upper back due to trauma from a rock while doing sit-ups in boot camp and (ii) an injury to the Veteran's upper back when a 150-pound wrecker chain unraveled and landed on him. (The Board notes that for purposes of the medical examination and etiology opinion, both these injuries should be taken as having in fact occurred.) The Board notes that the Veteran's upper back is considered to have been in normal, sound health at his entrance to service, and the Board notes that the Veteran was ultimately medically discharged from service due to the medical board's diagnosis of "upper back pain, etiology undetermined." 2. After the above development and any other development deemed necessary is completed, readjudicate the Veteran's claims. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Davis, Associate 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.