Citation Nr: 21044706 Decision Date: 07/21/21 Archive Date: 07/21/21 DOCKET NO. 15-46 457 DATE: July 21, 2021 ORDER The application to reopen a claim of service connection for spinal fusion with vertebral fracture is granted. Service connection for residuals of a cervical spine injury, to include quadriplegia, as secondary to right and left lower extremity peripheral neuropathy and a back disability, is granted. Service connection for neurogenic bladder, as secondary to service-connected residuals of a cervical spine injury, to include quadriplegia, is granted. Service connection for neurogenic bowel, as secondary to service-connected residuals of a cervical spine injury, to include quadriplegia, is granted. Special monthly compensation (SMC) based on aid and attendance pursuant to 38 U.S.C. § 1114(l) is granted. SMC based on housebound pursuant to 38 U.S.C. § 1114(s) is dismissed. REMANDED A rating in excess of 20 percent for right lower extremity peripheral neuropathy and lumbar radiculopathy. A rating in excess of 20 percent for left lower extremity peripheral neuropathy and lumbar radiculopathy. A rating in excess of 20 percent for right upper extremity peripheral neuropathy. A rating in excess of 20 percent for right upper extremity peripheral neuropathy. FINDINGS OF FACT 1. Residuals of a cervical spine injury, to include quadriplegia, were caused by the Veteran's service-connected right and left lower extremity peripheral neuropathy and back disability. 2. Neurogenic bladder was caused by the Veteran's service-connected residuals of a cervical spine injury, to include quadriplegia. 3. Neurogenic bowel was caused by the Veteran's service-connected residuals of a cervical spine injury, to include quadriplegia. 4. As the result of service-connected disability, the Veteran is with such significant disabilities as to be in need of regular aid and attendance. 5. SMC based on aid and attendance pursuant to 38 U.S.C. § 1114(l) is a greater benefit than SMC based on housebound pursuant to 38 U.S.C. § 1114(s). CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of a cervical spine injury, to include quadriplegia, as secondary to right and left lower extremity peripheral neuropathy and a back disability, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for neurogenic bladder, as secondary to residuals of a cervical spine injury, to include quadriplegia, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for neurogenic bowel, as secondary to residuals of a cervical spine injury, to include quadriplegia, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for SMC pursuant to 38 U.S.C. § 1114(l) have been met. 38 U.S.C. § 1114; 38 C.F.R. §§ 3.350, 3.352. 5. Entitlement to SMC based on housebound pursuant to 38 U.S.C. § 1114(s) is dismissed as moot. 38 U.S.C. § 1114; 38 C.F.R. § 3.350. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1967 to November 1970. The case is on appeal from November 2014 (lower extremity increased rating claims), September 2018 (SMC claims) and February 2019 (upper extremity increased rating claims and bladder and bowel service connection claims) rating decisions. In September 2019, the Board remanded the lower extremity increased rating claims. 1. Application to reopen a claim of service connection for spinal fusion with vertebral fracture. This issue was not addressed by the RO, but as will be explained, is reasonably encompassed within the scope of the Veteran's service connection claims for bladder and bowel disabilities that the RO did address in the February 2019 rating decision on appeal. In January 2017, the Veteran filed a claim for service connection for a cervical spinal cord injury (which he characterized as "C3-6 SCI"). See January 2017 VA Form 21-526EZ. He noted that this disability was being claimed secondary to various service-connected disabilities, to include a back disability (he is service-connected for "degenerative disc disease, status post L5-S1 disc surgery") and bilateral lower extremity radiculopathy and peripheral neuropathy. The Veteran was afforded a February 2017 VA examination and a Neck (Cervical Spine) Conditions Disability Benefits Questionnaire (DBQ). The DBQ noted that the Veteran "states in August 2016 was walking down stairs when he tripped. He states he sustained a fracture at the C-5 level and underwent a cervical spinal fusion at that time. He is now with residual quadr[i]plegia." In a June 2017 rating decision, the RO denied service connection for "spinal fusion with vertebral fracture (also claimed as cervical injury, C3-6 SCI with quadriplegia." The Veteran was notified of the decision by letter later that month, which was mailed to the then current mailing address of record. No new and material evidence or notice of disagreement (NOD) was received by VA within one year of the issuance of the June 2017 rating decision. As the Veteran did not appeal the decision, that rating decision is final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. In November 2018, the Veteran submitted a VA Form 21-526EZ and listed a disability of "loss of bowel and bladder" and noted "secondary to [service connected] conditions." In a February 2019 rating decision, the RO denied "[s]ervice connection for loss of use of" bladder and bowel "secondary [to service-connected] conditions." The Veteran appealed this rating decision in a May 2019 NOD and a December 2019 SOC characterized the issues on appeal the same way as the February 2019 rating decision. As part of this claim, the Veteran was afforded a VA examination in January 2019 and a Diabetes DBQ was completed by Dr. B.R., who stated that "the Veteran is status post a fall in July of 2016 that resulted in a spinal cord injury rendering him partially paralyzed." Dr. B.R. also provided a negative opinion as to the issue of whether the claimed bladder and bowel disabilities were secondary to diabetes, but Dr. B.R. also stated that "there is a readily available explanation for the Veteran's bowel and bladder condition, which had an acute onset with the Veteran's spinal trauma, that being this spinal injury itself." As such, this evidence indicated that the Veteran had bladder and bowel disabilities that were due to his cervical spine injury residuals. The Veteran also submitted in May 2019 a copy of a statement from Dr. C.O., a VA doctor with a listed title of "Chief, Spinal Cord Clinic." Dr. C.O. stated that the Veteran "had a fall down the stairs in 2016. It is more likely than not to have been contributed to by his peripheral neuropathy of his right and left lower extremities and/or his lumbar disc disease." This statement is relevant because various evidence indicated that, as a result of the referenced fall, the Veteran sustained a cervical spine injury that resulted in residuals, to include quadriplegia. See, e.g., January 2019 VA Diabetes DBQ; August 2018 VA Physical Medicine Rehab Consult (Dr. G.S. stating that the Veteran "suffered a C5 spinal cord injury from a fall on July 10, 2016 and developed tetraparesis"); August 2019, April 2019, June 2018 and April 2018 VA Orthopedic Notes (Dr. L.L. stating "C5 quadriplegic following a fall in [July 2016]"); September 2016 VA Physician Discharge Note (Dr. T.L. stating that the Veteran "presents with weakness following spinal cord injury. [The Veteran] suffered injury in July after falling down stairs with injury to C3-6)"). As such, Dr. C.O.'s statement related to the issue of whether the Veteran's cervical spine injury and residuals were secondary to service-connected disabilities, specifically right and left lower extremity peripheral neuropathy and/or a back disability. In DeLisio v. Shinseki, 25 Vet. App. 45 (2011), the United States Court of Appeals for Veterans Claims (Court) addressed in depth the issue of the scope of a claim with respect to claims involving secondary service connection. As relevant, the Court stated: if the condition for which VA benefits are sought is not directly associated with service, but information obtained during the processing of the claim reasonably indicates that the cause of the condition is a disease or other disability that may be associated with service, [VA] generally must investigate whether the causal disease or disability is related to service, in order to determine whether the claimed condition is related secondarily to service...if [VA] determines that the causal disease or disability is, in fact, connected to service, then the claim for benefits for the condition 'reasonably encompasses' a claim for that causal disease or disability, such that no additional filing is necessary to initiate a claim for benefits for the causal disease or disability. [...] [W]e hold that, when a claim is pending and information obtained reasonably indicates that the claimed condition is caused by a disease or other disability that may be associated with service, [VA] generally must investigate the possibility of secondary service connection; and, if that causal disease or disability is, in fact, related to service, the pending claim reasonably encompasses a claim for benefits for the causal disease or disability, such that no separate filing is necessary to initiate a claim for benefits for the causal disease or disability. The Board finds that, applying DeLisio, the scope of the Veteran's bladder and bowel service connection claims on appeal reasonably encompassed a claim for service connection for residuals of a cervical spine injury. Specifically, the Veteran filed a November 2018 claim that was construed by the RO as for service connection for loss of use of bladder and bowel. Information obtained while this claim was pending, specifically the January 2019 VA opinion from Dr. B.R., reasonably indicated that the claimed bladder and bowel conditions were caused by the Veteran's 2016 fall and cervical spine injury. In addition, evidence, specifically the May 2019 statement from Dr. C.O., indicated that this cervical spine injury may be associated with service by way of being secondary to service-connected disabilities. This evidence required VA to investigate whether the causal disability (the cervical spine injury and residuals) is related to service, in order to determine whether the claimed condition (bladder and bowel disabilities) are related secondary to service. As will be outlined further below, the Board finds that the causal disability (the cervical spine injury and residuals) is in fact connected to service, by way of secondary service connection to service-connected right and left lower extremity peripheral neuropathy and a back disability. As such, the November 2018 claim for bladder and bowel disabilities reasonably encompassed a claim for the causal disability (the cervical spine injury and residuals) and "no separate filing is necessary to initiate a claim for benefits for the causal disease or disability." See DeLisio, 25 Vet. App. at 55. In light of the prior final June 2017 rating decision, the November 2018 claim that reasonably encompassed a claim for residuals of a cervical spine injury is properly characterized as an application to reopen the previously denied claim. As to this issue, the Board finds that new and material evidence has been submitted so that the previously denied claim of service connection for spinal fusion with vertebral fracture is reopened. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a); see also May 2019 Dr. C.O. Statement. 2. Service connection for residuals of a cervical spine injury, to include quadriplegia. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. See 38 C.F.R. § 3.310. As discussed above, various evidence indicated that the Veteran experienced a fall in 2016 and that as a result he sustained a cervical spine injury that resulted in residuals, to include quadriplegia. The Veteran has contended that his cervical spine injury was secondary to his service-connected right and left lower extremity peripheral neuropathy and a back disability. See January 2017 VA Form 21-526EZ. The February 2017 Neck Conditions DBQ stated that the Veteran "is seeking service connection for his fractured cervical spine condition that he claimed to have occurred because of the weakness of his lower extremities and knees." The Veteran's contention appears to have been, therefore, that he experienced the fall because of symptomatology, such as weakness, associated with his service-connected right and left lower extremity peripheral neuropathy and back disability. Evidence dated prior to the 2016 fall indicated that the Veteran did experience symptomatology in his lower extremities and that his ambulation was impaired. In this regard, in a December 2015 statement accompanying his VA Form 9 (for the appeal of the lower extremity increased rating claims), the Veteran stated that "I have a problem with ambulation, period," that "[a]fter I sit for 15 to 20 minutes, it will take me approximately 20 minutes of ambulation in order for my legs to become stable enough for me to move around without some type of prosthetic support (cane, walker or crutch)" and "[b]oth my lower extremities are always numb, tingle and feel cold. Even my calves hurt and cause me to feel fatigued and...physical exhausted." The most recent relevant VA examinations prior to the 2016 fall included an October 2014 Diabetic Sensory-Motor Peripheral Neuropathy DBQ and a July 2014 Back (Thoracolumbar Spine) Conditions DBQ. The October 2014 Peripheral Neuropathy DBQ stated that the Veteran "has lumbar radiculopathy in both legs in addition to pain and numbness in both feet," noted severe constant pain (may be excruciating at times) and moderate numbness in the right and left lower extremities, noted upon neurologic exam reduced strength for knee flexion (4/5 for the right and 3/5 for the left) and for left ankle plantar flexion and dorsiflexion (3/5) and noted decreased light touch/monofilament testing for the left knee/thigh, ankle/lower leg and foot/toe. The Board notes that a November 2014 rating decision increased the assigned rating for right lower extremity peripheral neuropathy and lumbar radiculopathy and the codesheet noted that such was granted "as exam shows objective loss of strength in knees." The July 2014 Back Conditions DBQ noted the Veteran's report of experiencing flare-ups "about 60 70% of the time or better majority of the time, it like a burning, throbbing, pain, if [I] stand to long or sit down a long period of time, walking that whats aggravates it." The DBQ also noted that the Veteran experienced functional loss or functional impairment after repetitive use, specifically excess fatigability, pain on movement, interreference with sitting, standing and/or weight-bearing and "balance gait unsteady aide dependent." The DBQ also noted reduced muscle strength for knee flexion (4/5) bilaterally. As discussed above, the Veteran also submitted in May 2019 a copy of a statement from Dr. C.O., a VA doctor with a listed title of "Chief, Spinal Cord Clinic." Dr. C.O. stated that the Veteran "had a fall down the stairs in 2016. It is more likely than not to have been contributed to by his peripheral neuropathy of his right and left lower extremities and/or his lumbar disc disease." While not fully articulated, presumably Dr. C.O.'s opinion was based on the symptomatology associated with these disabilities contributing to the fall. The Board notes that VA treatment records reflected that Dr. C.O. treated the Veteran on various occasions over a multi-year period. Such records included a January 2017 "Spinal Cord Injury Initial Evaluation Note" and notes with a title of "[Spinal Cord Injury] Followup Note" in July 2017, January 2018, July 2018, September 2018, January 2019 and August 2019 (two notes). As such, Dr. C.O. was presumably familiar with the Veteran's medical history, functional impairment and the circumstances surrounding his 2016 fall. Overall, Dr. C.O. indicated that the Veteran's service-connected right and left lower extremity peripheral neuropathy and back disability contributed to his 2016 fall, which was shown by various evidence to have resulted in residuals, to include quadriplegia. As such, Dr. C.O.'s statement, taken with the other evidence of record indicating that the 2016 fall resulted in residuals, offers competent and probative evidence indicating that the Veteran's cervical spine injury and residuals were secondary to his service-connected right and left lower extremity peripheral neuropathy and back disability. As part of the earlier claim, VA obtained two negative secondary service connection opinions in February 2017 (addressing whether a cervical spine injury was secondary to lower extremity disabilities) and April 2017 (addressing whether a cervical spine injury was secondary to a back disability). The January 2017 VA opinion (from Nurse Practitioner R.D.) stated that "[t]he two conditions are not medically related. The claimed disorder is a separate entity entirely from the service connected condition and unrelated to it. The medical literature does not support a medical relationship. A nexus has not been established." The April 2017 VA opinion (from Physician Assistant E.E.) stated that "[t]he conditions are not medically related. The claimed disorder is a separate entity entirely from the service connected conditions and unrelated to it. The evidence of record does not support a causal relationship between the service connected conditions and the circumstances of the cervical spine injury" and "[d]ue consideration has been given to potential contributing factors of symptoms of the service connected conditions. A nexus has not been established." Review of these two opinions indicates that neither opinion clearly addressed whether the Veteran's service-connected disabilities contributed to his 2016 fall, as articulated by Dr. C.O. As such, they are not probative as to this issue and do not offer competent evidence contrary to Dr. C.O.'s provided conclusion. The Board notes that there is otherwise no competent evidence contrary to Dr. C.O.'s opinion. As to the specific issue of whether the Veteran's service-connected right and left lower extremity peripheral neuropathy and back disability contributed to the 2016 fall that resulted in a cervical spine injury and residuals, the Board finds Dr. C.O.'s opinion to be the most probative evidence of record. The Board finds that this opinion indicated that the Veteran's service-connected right and left lower extremity peripheral neuropathy and back disability contributed to his 2016 fall, which was shown by various evidence to have resulted in residuals, to include quadriplegia. As such, and resolving any reasonable doubt in the Veteran's favor, the Board finds that Dr. C.O.'s statement, taken with the other evidence of record, sufficiently indicated that the Veteran's cervical spine injury and residuals were secondary to his service-connected right and left lower extremity peripheral neuropathy and back disability. In sum, the Board finds that the residuals of a cervical spine injury, to include quadriplegia, were caused, at least in part, by the Veteran's service-connected right and left lower extremity peripheral neuropathy and back disability. This is particularly so when reasonable doubt is resolved in his favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, service connection for residuals of a cervical spine injury, to include quadriplegia, is warranted. 3. Service connection for neurogenic bladder. 4. Service connection for neurogenic bowel. As referenced above, the Veteran was afforded a January 2019 VA examination and a Diabetes DBQ was completed by Dr. B.R. The DBQ stated that "the Veteran is status post a fall in July of 2016 that resulted in a spinal cord injury rendering him partially paralyzed and necessitating the placement of a suprapubic catheter for urine drainage and the use of promotility suppositories to facilitate timed defecation to assist his caregiver." Dr. B.R. also provided a negative opinion as to the issue of whether the claimed bladder and bowel disabilities were secondary to diabetes, but Dr. B.R. also stated that "there is a readily available explanation for the Veteran's bowel and bladder condition, which had an acute onset with the Veteran's spinal trauma, that being this spinal injury itself." As such, Dr. B.R.'s opinion indicated that the Veteran's bowel and bladder conditions were due to his cervical spine injury. The Board notes that there is no competent opinion contrary to Dr. B.R.'s conclusion that the Veteran experienced bladder and bowel disability as a result of his cervical spine injury. As referenced, VA Dr. C.O. treated the Veteran on various occasions over a multi-year period. His notes consistently noted diagnoses of neurogenic bladder and neurogenic bowel. Based on Dr. B.R.'s January 2019 VA opinion and Dr. C.O.'s treatment records, and resolving any reasonable doubt in the Veteran's favor, the Board finds that the Veteran's neurogenic bladder and neurogenic bowel were secondary to his cervical spine injury. In sum, the Board finds that the Veteran's neurogenic bladder and neurogenic bowel were caused by his service-connected (as granted in this decision) residuals of a cervical spine injury. This is particularly so when reasonable doubt is resolved in his favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, service connection for neurogenic bladder and neurogenic bowel is warranted. 5. SMC based on aid and attendance pursuant to 38 U.S.C. § 1114(l). Procedurally, the Veteran submitted a July 2018 VA Form 21-2680 (Examination for Housebound Status or Permanent Need for Regular Aid and Attendance). In a September 2018 rating decision, the RO denied "[e]ntitlement to [SMC] based on aid and attendance/housebound." The December 2019 statement of the case (SOC) listed the issue on appeal as "[e]ntitlement to [SMC] based on aid and attendance/housebound." The Board notes that SMC based on aid and attendance and housebound have distinct requirements. See 38 U.S.C. § 1114(l) (regarding aid and attendance), 38 U.S.C. § 1114(s) (regarding housebound). In light of the procedural history and the RO's clear adjudication of both SMC based on aid and attendance and housebound, the Board will address both issues. In light of the distinct requirements for each type of SMC, the Board has characterized these as separate issues on appeal and will address them separately. Legal Criteria 38 U.S.C. § 1114(l) provides, as relevant, that compensation is warranted "if the veteran, as the result of service-connected disability... is...with such significant disabilities as to be in need of regular aid and attendance." See also 38 C.F.R. § 3.350(b). 38 C.F.R. § 3.350(b)(3) states that "[t]he criteria for determining that a veteran is so helpless as to be in need of regular aid and attendance are contained in § 3.352(a)." 38 C.F.R. § 3.352(a) provides, as relevant, that : The following will be accorded consideration in determining the need for regular aid and attendance...: inability of claimant to dress or undress himself (herself), or to keep himself (herself) ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid...; inability of claimant to feed himself (herself) through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment...It is not required that all of the disabling conditions enumerated in this paragraph be found to exist before a favorable rating may be made. The particular personal functions which the veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that the veteran is so helpless, as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant's condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others. Analysis The Board finds that entitlement to SMC pursuant to 38 U.S.C. § 1114(l) is warranted following the grant of service connection for residuals of a cervical spine injury, to include quadriplegia. As to this issue, the Board finds particularly probative three VA Form 21-2680s. The first is from February 2017 and was completed by VA Dr. V.B., who appears to be the Veteran's primary care provider based on a review of VA treatment records. See December 2015, March 2016, December 2016, November 2017, July 2018 and July 2019 VA Primary Care Treatment Notes. A diagnosis was noted of spinal cord injury and the disability that restricted the listed activities/functions was noted as "paraplegic." It was noted that the Veteran was not able to feed himself, that he was not able to prepare his own meals, that he needed assistance in bathing and tending to other hygiene needs and that he required medication management. It was also noted that the Veteran required nursing home care. A July 2018 VA Form 21-2680 was completed by VA Dr. C.O., who as discussed above, treated the Veteran on various occasions over a multi-year period. A diagnosis was noted of "quadriplegia C5-7" and the disability that restricted the listed activities/functions was noted as "[q]uadriplegia." It was noted that the Veteran was not able to feed himself due to arm atrophy, that he was not able to prepare his own meals, that he needed assistance in bathing and tending to other hygiene needs and that he required medication management. A June 2021 VA Form 21-2680 was completed by VA Dr. V.B. Multiple diagnoses were listed, but the disability that that restricted the listed activities/functions was noted as "spinal cord injury." It was noted that the Veteran was not able to feed himself and it was stated "Veteran unable to grasp utensils; he is fe[]d by family." It was noted that he was not able to prepare his own meals and it was stated that "Veteran unable to hold any objects in hand; Therefore, he is unable to microwave a meal. Family prepare meals." It was noted that he needed assistance in bathing and tending to other hygiene needs and it was stated that the Veteran "is total care due to spinal cord injury. Family completes all [activities of daily living]." It was also noted that the "Veteran is quadriplegic, doesn't have control of bowel or bladder. Veteran has supra-pubic catheter, unable to care for per self due to inability to grasp objects." It was noted that the Veteran does not require nursing home care, but it was stated that "Veteran would require nursing home care if family wasn't present due to being total care related to spinal cord injury." It was also noted that the Veteran required medication management and it was stated that "Veteran unable to open medication bottles. Daughter sets up his meds for the week. His grandkids are home to give administer medications and food/fluids on daily basis." The Board finds these examination reports, which were dated over a multi-year period and completed by two VA doctors that had treated the Veteran for an extended period of time, particularly probative as to the issue of whether SMC pursuant to 38 U.S.C. § 1114(l) is warranted. Such examination reports indicated that the Veteran was in need of regular aid and attendance due to his (as granted in this decision) service-connected residuals of a cervical spine injury, to include quadriplegia. In sum, the Board finds that, as the result of service-connected disability, the Veteran is with such significant disabilities as to be in need of regular aid and attendance. This is particularly so when reasonable doubt is resolved in his favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, SMC based on aid and attendance pursuant to 38 U.S.C. § 1114(l) is warranted. 6. SMC based on housebound pursuant to 38 U.S.C. § 1114(s). As noted, the Board has granted entitlement to SMC pursuant to 38 U.S.C. § 1114(l). SMC based on aid and attendance is a greater benefit than SMC based on housebound. Compare 38 U.S.C. § 1114(l) (noting that monthly compensation for SMC based on aid attendance "shall be $3,327"); with 38 U.S.C. § 1114(s) (noting that monthly compensation for SMC based on housebound "shall be $2,993"). As such, the issue of entitlement to SMC based on housebound is moot because the Veteran has been granted the greater benefit of SMC based on aid and attendance. Entitlement to SMC based on housebound pursuant to 38 U.S.C. § 1114(s) is accordingly dismissed as moot. 38 U.S.C. § 1114; 38 C.F.R. § 3.350. REASONS FOR REMAND 1. A rating in excess of 20 percent for right lower extremity peripheral neuropathy and lumbar radiculopathy. 2. A rating in excess of 20 percent for left lower extremity peripheral neuropathy and lumbar radiculopathy. 3. A rating in excess of 20 percent for right upper extremity peripheral neuropathy. 4. A rating in excess of 20 percent for right upper extremity peripheral neuropathy. The Board finds that remand is required for all of these increased rating claims, in light of the Board's grant in this decision of service connection for residuals of a cervical spine injury, to include quadriplegia. Following this decision, the RO will assign an effective date of service connection and a disability rating in the first instance for the newly service-connected disability. The assigned rating may overlap with the ratings and symptomatology associated with that of the increased rating disabilities on appeal and therefore may raise issues as to pyramiding. See 38 C.F.R. § 4.14 (titled "Avoidance of pyramiding" and stating that "[t]he evaluation of the same disability under various diagnoses is to be avoided. Disability from injuries to the...nerves...may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation"). In this regard, Diagnostic Code (DC) 5244 is titled "Traumatic paralysis, complete" and states "Quadriplegia: Rate separately under DCs 5109 and 5110." An accompanying note states that "[i]f traumatic paralysis does not cause loss of use of both hands or both feet, it is incomplete paralysis. Evaluate residuals of incomplete traumatic paralysis under the appropriate diagnostic code (e.g., § 4.124a, Diseases of the Peripheral Nerves." As such, the Board finds that the increased rating claims on appeal are, at this time, inextricably intertwined with the initial rating(s) to be assigned for the newly service-connected residuals of a cervical spine injury, to include quadriplegia, and that remand is therefore appropriate. See Harris v. Derwinski, 1 Vet. App. 180 (1991). While on remand, outstanding VA treatment records should also be obtained. The matters are REMANDED for the following action: 1. Obtain outstanding VA treatment records. 2. Following the assignment of the initial rating(s) for the newly service-connected residuals of a cervical spine injury, to include quadriplegia, readjudicate the remanded increased rating claims. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Hoopengardner, 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.