Citation Nr: 21032049 Decision Date: 05/25/21 Archive Date: 05/25/21 DOCKET NO. 16-31 858 DATE: May 25, 2021 REMANDED Entitlement to service connection for cervical degenerative disc disease with spondylolisthesis, stenosis, and myelomalacia is remanded. REASONS FOR REMAND The Veteran had active naval service from August 1980 to March 1996. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. The case was previously before the Board in March 2019, at which time the issue currently before the Board was remanded for additional development. The case has now been returned to the Board for further appellate action. Entitlement to service connection for cervical degenerative disc disease with spondylolisthesis, stenosis, and myelomalacia is remanded. A remand is necessary in order to ensure compliance with the March 2019 Board remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In the March 2019 remand, the Board directed that a VA medical opinion be obtained to address whether the Veteran's current cervical conditions are related to his claimed in-service head injury. The Veteran has provided a buddy statement indicating that the Veteran busted his head open while serving on the USS Nimitz. Service treatment records show a complaint of posterior neck pain in October 1995 and a complaint of headaches and neck pain in November 1995. A post-service June 1996 VA examination showed a diagnosis of cervical strain. The directed medical opinion was obtained in January 2020. At that time, the VA examiner opined that the Veteran's cervical spine degenerative changes with findings most prominent at C3-4 with moderate canal stenosis, and signal abnormality in the cord suggestive myelomalacia-per post separation MRI cervical spine-9/11/2014, eighteen and one-half years after active separation is less likely than not incurred in or caused by active military service. In so finding, the VA examiner reasoned that the STRs were silent for either an acute or chronic disabling neck/cervical spine condition or any associated chronic, disabling functional deficits/limitations. The examiner further opined that the Veteran's 1990 head injury and the July 2016 buddy statement did not support that the Veteran sustained a chronic disabling neck/cervical spine condition prior to active service, during, or since active service and separation to date. The Board finds that the January 2020 medical opinion is inadequate. The January examiner did not seriously consider the Veteran's lay contentions that his cervical neck conditions were due to a head injury that occurred in 1990 while serving aboard the USS Nimitz and that his related symptoms have continued since that time. Rather, the examiner relied on the inaccurate factual premise that the "STRs were silent" for a neck disability. Therefore, remand for an addendum opinion is warranted. Stegall, 11 Vet. App. at 268. The matter is REMANDED for the following action: 1. Identify and obtain any outstanding pertinent VA and private records and associate them with the claims file. 2. Forward the Veteran's claims file to the VA Medical Center for an addendum medical opinion by a qualified physician, to determine the nature and etiology of the Veteran's cervical neck disability. The claims file must be made available to and reviewed by the physician. Based on a review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that the Veteran's cervical degenerative disc disease with spondylolisthesis, stenosis, and myelomalacia is etiologically related to an incident of his military service or any symptomatology noted in service, to include service treatment records dated October and November 1995. In forming the opinion, the examiner must consider the Veteran's report of a 1990 head injury while serving aboard the USS Nimitz, and the continued symptoms during and after service, along with a July 2016 buddy statement indicating that the Veteran "bust[ed] his head open" while serving on the USS Nimitz. The rationale for the opinion expressed must be provided. Another VA examination of the Veteran should only be conducted if deemed necessary by the VA examiner that provided the requested medical opinion. 3. Confirm that the VA examination and the medical opinion provided comport with this remand and undertake any other development determined to be warranted. (Continued on the next page) 4. Then, readjudicate the appeal. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. Roya Bahrami Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Ivan Franklin 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.