Citation Nr: 22010734 Decision Date: 02/24/22 Archive Date: 02/24/22 DOCKET NO. 17-03 871 DATE: February 24, 2022 REMANDED Entitlement to service connection for a left upper extremity neurological disability, claimed as carpal tunnel is remanded. INTRODUCTION The Veteran had active service from April 1988 to March 1996. In September 2019, the Veteran attended a hearing before the undersigned Veterans Law Judge. A transcript of that proceeding is of record. When this case was previously before the Board in March 2020, March 2021, and October 2021, the above-noted issue was remanded for further development. The case has since been returned for additional appellate review. REASONS FOR REMAND Although frustrating, the Board finds additional development is necessary prior to final adjudication of the above-noted issue on appeal. In the course of the October 2021 decision, the Board found an addendum medical opinion was necessary from an August 2021 VA examiner. The Board observed that the August 2021 examiner diagnosed the Veteran with bilateral CTS. Though the examiner found the Veteran's right CTS was aggravated by a malfunctioning morphine pump used to treat his service-connected lumbar spine disability, he curiously concluded the Veteran's left CTS was less likely than not caused or aggravated by his service-connected lumbar spine disability. In support of this conclusion, the examiner explained that a malfunctioning morphine pump would only be expected to affect one side, and as such, his left upper extremity CTS was less likely than not aggravated by his service-connected lumbar spine disability. The examiner did not explain how or why he came to this conclusion. As such, the Board requested an addendum report from the August 2021 examiner. Thereafter, the RO obtained addendum medical opinions from an examiner who did not conduct the August 2021 examination. In sum, the examiner indicated the Veteran's left CTS was less likely than not caused or aggravated by his lumbar spine disability. In his initial November 2021 opinion, the examiner indicated there is no medical rationale correlating the diagnosis of a lumbar spine condition with the aggravation of a pre-existing carpal tunnel syndrome. Clearly, the examiner failed to appreciate the theory of entitlement claimed. Thereafter, in December 2021 the examiner provided a cursory response indicating the "location of the placement of the morphine and migration of the pump" made it less likely than not that the pump caused or aggravated the Veteran's left CTS. This is essentially the same conclusory statement provided by the August 2021 examiner, and again wholly fails to explain how or why the location of the pump made its malfunction less likely than not to have caused or aggravated his left CTS. What is more perplexing, is the examiner then went on to explain that a morphine pump is inserted into the abdomen, and a small catheter is then inserted through a needle into the spinal fluid space. This explanation seems to only further cloud the August 2021 examiner's conclusion that the malfunctioning pump would only affect one upper extremity, as the pump was not located in that extremity. A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Since substantial compliance with the Board's prior remand instructions has not been achieved, a remand is unfortunately again required. Accordingly, this case is REMANDED for the following actions: Obtain an addendum medical opinion from the physician that conducted the Veteran's August 2021 VA peripheral nerves examination, if available, and if unavailable from a Neurologist with sufficient expertise to comment on the etiology of the Veteran's left upper extremity carpal tunnel syndrome. All pertinent evidence of record should be made available to and reviewed by the examiner. A new examination should only be conducted if deemed necessary by the examiner. Following a review of the relevant records and lay statements, the examiner should state whether the Veteran's left extremity carpal tunnel syndrome at least as likely as not (a 50 percent probability or greater) was worsened to any degree by his service-connected lumbar spine disability. In this regard, the examiner is asked to fully explain how and why a malfunctioning morphine pump would only affect one extremity in this case. The examiner is asked to specifically consider and expressly discuss the Veteran's competent lay statements concerning the severity and manifestations of his left upper extremity CTS. The examiner is also asked to specifically consider and expressly discuss the June 2019 statement provided by the Veteran's treating physician, which indicates the Veteran has experienced several side effects associated with his malfunctioning morphine pump. The examiner must provide a complete rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Fraser, 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.