Citation Nr: 22010940 Decision Date: 02/24/22 Archive Date: 02/24/22 DOCKET NO. 15-42 101 DATE: February 24, 2022 REMANDED Entitlement to service connection for a recurrent cervical spine disability is remanded. Entitlement to a rating in excess of 10 percent for right lower extremity sciatic nerve radiculopathy is remanded. Entitlement to a rating in excess of 10 percent prior to March 30, 2021, and in excess of 20 percent on and after March 30, 2021, for left lower extremity sciatic nerve radiculopathy is remanded. Entitlement to a rating in excess of 20 percent for left lower extremity femoral nerve radiculopathy is remanded. REASONS FOR REMAND The Veteran had active service from June 1998 to August 1999. 1. Entitlement to service connection for a recurrent cervical spine disability is remanded. Service connection may be granted for disability which is proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310(a). Service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310(a) where it is demonstrated that a service connected disorder has aggravated a nonservice connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection is currently in effect for fibromyalgia, lumbosacral spine degenerative disc disease, right sciatic nerve radiculopathy, left sciatic nerve radiculopathy, left femoral nerve radiculopathy, an unspecified depressive disorder, a left shoulder disability, right hip bursitis and limitation of abduction, and left hip bursitis and limitation of abduction. The report of an October 2021 cervical spine examination conducted for the Department of Veterans Affairs (VA) states that the Veteran reported having injured her cervical spine during active service "because of carrying the gear." The Veteran was diagnosed with cervical strain. The examiner concluded that the diagnosed cervical spine strain is not related to military service as "[t]here has never been a diagnosis other than strain or cervicalgia that related to her neck" and "due to these reasons, there is no way to link her current neck pain/diagnosis with service from 22 years ago without more evidence in that span of years." The physician assistant did not address the relationship, if any, between the diagnosed cervical spine strain and the service connected lumbosacral degenerative disc disease reported cervical spine pain and the service-connected lumbosacral spine disability and fibromyalgia. In light of such deficiency, the Board of Veterans' Appeals (Board) finds that the examination report is of limited probative value. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Further VA cervical spine evaluation is needed. 2. Entitlement to a rating in excess of 10 percent for right lower extremity sciatic nerve radiculopathy; a rating in excess of 10 percent prior to March 30, 2021, and in excess of 20 percent on and after March 30, 2021, for left lower extremity sciatic nerve radiculopathy; and a rating in excess of 20 percent for left lower extremity femoral nerve radiculopathy is remanded. In its July 2021 Remand instructions, the Board requested that the Veteran be scheduled for a VA examination addressing the lower extremity radiculopathy. The examiner was directed to provide a retrospective opinion "regarding the nature and severity of the Veteran's lower extremity radicular symptoms, under the criteria of 38 C.F.R. § 4.124A, during the appeal period from October 2014 to the present." The report of an October 2021 peripheral nerve examination conducted for VA states that the examiner conveyed that: "[t]here is honestly no way to reconcile the conflicting VA examination reports regarding the severity of the veteran's radicular symptoms;" "when doing a peripheral nerve exam, it is highly subjective for most parts;" and "without being present or personally conducting the past exams, I cannot reconcile the conflicting reports." The physician assistant was expressing her limitations in being unable to render the requested opinion. Therefore, the Board finds that further VA peripheral nerve evaluation is needed. Clinical documentation dated after November 2021 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, these matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated any cervical spine disabilities and the service connected right lower extremity and left lower extremity radiculopathy. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after November 2021. 3. Schedule the Veteran for a VA cervical spine examination conducted by a medical doctor to assist in determining the nature and etiology of any identified cervical spine disability and any relationship to active service. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all cervical spine disabilities found. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified cervical spine disability had its onset during active service or is causally related to any incident of service, including the documented lumbar spine injury. (c) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified cervical spine disability is due to or caused by the lumbosacral spine degenerative disc disease, fibromyalgia, and the other service-connected disabilities. (d) Opine whether it at least as likely as not (50 percent probability or greater) that any identified cervical spine disability has been aggravated (increased in severity beyond the natural progression of the disorder) by the lumbosacral spine degenerative disc disease, fibromyalgia, and the other service-connected disabilities. 4. Schedule the Veteran for a VA neurological examination conducted by an appropriate physician to assist in determining the severity of the service connected right lower extremity and left lower extremity radiculopathy. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should describe any identified lower extremity radiculopathy; the nerves affected; and the level of impairment for the period from October 2014 to the date of the examination. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Marsdale 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.