Citation Nr: 21032136 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 17-35 164 DATE: May 26, 2021 REMANDED 1. Entitlement to service connection for a neck disability is remanded. 2. Entitlement to service connection for a left upper extremity nerve condition, to include as secondary to a neck disability, is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from July 1972 to February 1975. These matters are before the Board of Veterans' Appeals (Board) on appeal of an August 2014 Department of Veterans Affairs (VA) rating decision. In December 2020, a virtual hearing was held before the undersigned; a transcript is in the record. 1. 2. Entitlement to service connection for a neck disability and a left upper extremity nerve disability. The Board finds that further development of the record is needed for a proper adjudication of these claims. The Veteran alleges his neck disability is related to injuries sustained in service and that he has a left upper extremity nerve disability that is due to his neck disability. At the outset, it appears that pertinent VA records (of continued treatment for a neck and left upper extremity nerve condition) are outstanding. On April 2021, the Veteran submitted some VA treatment records from 2019 and 2020 showing ongoing treatment for a neck disability and left upper extremity numbness. A review of the record finds complete VA treatment records from the Louisville VAMC since May 2017 have not been obtained. VA treatment records are constructively of record, and development for any pertinent VA records that are outstanding is necessary. The Veteran's service treatment records (STRs) show he was seen multiple times in service for neck complaints. See July 1973 STR, August 1973 STR, and October 1973 report of medical history. March and April 2014 VA treatment records note complaints of neck pain and left arm numbness that started 2 weeks prior. He reported he had similar symptoms in the past, and that the current episode started after picking up a heavy object, and that he had seen a chiropractor for relief of prior symptoms. Mild cervical spine degenerative disease and acute cervical radiculopathy were diagnosed. On May 2014 VA examination, the Veteran reported his neck pain started in 1973, that had an additional neck injury in 1974, and that neck pain has continued since service. Degenerative arthritis of the cervical spine was diagnosed. In an opinion against the claim, the examiner noted a July 1973 report of an assessment of a neck sprain, but opined there is no further record of neck complaints in service. She did not address the Veteran's reports of continuing symptoms, the report of back pain in an October 1973 report of medical history, or indication in his VA treatment records that he received treatment prior to 2014. The opinion is based on consideration of an incomplete record, and is inadequate for rating purposes. The May 2014 examiner also opined the Veteran's history is not definitive for cervical radiculopathy as his symptoms may also represent a separate, unrelated peripheral condition. The examiner did not provide an etiology opinion for any left upper extremity nerve condition. A June 2014 VA treatment record notes an MRI was ordered to assess the Veteran's left arm numbness and whether it may be related to a pinched nerve in his arm. A July 2014 MRI report found some nerves exiting the spine were being compressed. A July 2014 EMG report found no evidence of left median or left ulnar neuropathy or C5-T1 radiculopathy. The provider suspected a left cervical root pathology that may affect sensory-only fibers which would not be picked up by electrodiagnostic testing. As the record does not include an adequate examination and opinion regarding the nature and etiology of the Veteran's neck and claimed left upper extremity nerve disabilities, another examination to secure a fully adequate medical opinion in these matters is necessary. The matters are REMANDED for the following: 1. Ask the Veteran to identify the provider(s) of all evaluations and treatment (records of which are not already in the claims file) he has received for his neck and left upper extremity nerve complaints, and to submit authorizations for VA to secure for the record any private records of such evaluations and/or treatment. Obtain complete records of such evaluations and/or treatment from all providers identified. If any private records identified are not received pursuant to an AOJ request, the Veteran should be so notified and advised that ultimately, it is his responsibility to ensure that private records are received. Secure for the record updated (all outstanding) complete clinical records of VA evaluations and treatment the Veteran has received for his neck and left upper extremity nerve disabilities, specifically including complete up-to-date records of treatment at Louisville VAMC. 2. After the development requested above is completed, arrange for the record to be forwarded to an appropriate clinician for review and a medical advisory opinion regarding the etiology of his current neck disability. [If further examination is deemed necessary, it should be arranged.] The entire record (to include the complaints noted in service and any evidence of postservice continuity of complaints/symptoms) must be reviewed by the consulting provider. The consulting provider should: (a.) Identify (by diagnosis) each neck disability entity found/or shown by the record (b.) Identify the likely etiology for each neck disability entity diagnosed. Specifically, is it at least as likely as not (a 50% or greater probability) that the disability is etiologically related to the Veteran's service, to include as due to reported complaints therein? (c.) If a diagnosed neck disability is found to be unrelated to service, identify the etiology that is considered to be more likely (and explain why that is so). Include rationale with all opinions. If the rationale for a negative opinion is that the arthritis is due to the aging process (and not trauma) cite to the clinical findings and medical literature that support such distinction. 3. Also, arrange for a neurological examination of the Veteran to confirm he has a nerve disability of the left upper extremity, and, if so, ascertain its likely etiology. The Veteran's record must be reviewed by the examiner. The examiner should provide opinions that respond to the following: (a.) Does the Veteran have left upper extremity radiculopathy/nerve disability entity (if so, identify it by diagnosis)? (b.) Identify the likely etiology for any left upper extremity nerve disability found. Specifically, is it at least as likely as not (a 50% or greater probability) that it is etiologically related to the Veteran's service or was caused or aggravated by/is a neurological complication of his neck disability? In addressing this matter, the examiner must provide rationale addressing both causation and aggravation. (c.) If a left upper extremity nerve condition is determined to not have been incurred in service or caused or aggravated by a neck disability, identify the etiology for such disability that is considered to be more likely (and explain why that is so). All opinions must include rationale, that cites to supporting clinical data and medical principles. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Naumovich, 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.