Citation Nr: 22014668 Decision Date: 03/14/22 Archive Date: 03/14/22 DOCKET NO. 19-18 529 DATE: March 14, 2022 REMANDED Entitlement to service connection for a cervical spine and neck condition is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1988 to September 1992. This appeal is before the Board of Veterans' Appeals (Board) from a February 2017 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO) and in November 2021, the Veteran appeared and provided testimony before the undersigned Veterans Law Judge (VLJ) and a transcript of that hearing is associated with the claims file. For the reasons stated below, the Board finds a remand is warranted for further development; and, for the sake of clarity, will include a recitation of the pertinent evidence of record. In this case, the Veteran alleges his cervical spine and neck condition is the result of in-service football and motor vehicle accident injuries. Turning to the evidence of record, the service treatment records (STRs) indicate that in January 1990 he received stitches for a cut above his right eye after he hit his head on bleachers during a football game. On September 9, 1990, he was involved in a motor vehicle accident where his car was stationary, and he was hit from behind. On September 12, 1990, he voiced complaints related to neck pain that he experienced since his accident. The record notes he had mild tenderness on the C7 and indicates he was diagnosed with a neck strain. His separation reports of medical history and examination in July 1992 were devoid of any issues or notations related to his cervical spine or neck. VA records from September to December 2014 indicate he received treatment for neck pain that he alleged had been "intermittent" since his in-service accident. In February 2017 he underwent a VA cervical spine conditions examination report, and the report only addressed the Veteran's initial secondary service connection claim; however, the Veteran has since clarified and limited his claim to direct service connection only. See Hearing Transcripts at 2. Also in February 2017, attached to his notice of disagreement (NOD), he alleged his neck issues began shortly after his in-service car accident and it has continued ever since. The Veteran underwent an April 2018 VA examination to evaluate the Veteran's cervical spine service connection claim. An associated VA cervical spine x-ray revealed he had mild degenerative disc disease at C5-6. The medical opinion determined that it was less likely than not his cervical spine and neck disorder were the result of active service. The rationale for this opinion was as follows: "Service treatment records do not indicate neck complaints or treatment. Veteran reports that he did not seek medical care in regards to neck condition. Service separation exam dated 07/28/92 reveals neck exam was normal. veteran reported "low back trouble" and not neck. A nexus has not been established." Also in April 2018, the Veteran submitted a statement to the Board alleging his neck pain is the result of his in-service car accident and football injury. During his November 2021 Board hearing, he reiterated his allegation that his neck pain is the result of his in-service car accident and football injury. The Board notes that in addition to the above referenced records, the evidence also contains a multitude of VA records documenting treatment for the Veteran's neck pain and at no point does the Veteran allege nor does the record state a different date that his symptoms began. After a review of the claims file, the Board finds a remand for further development is warranted prior to adjudication of the Veteran's claim. In this case, the April 2018 VA examiner's opinion was based on the reported absence of STRs indicating "neck complaints or treatment;" and reported that the Veteran did not voice any complaints related to in-service neck pain. However, the evidence of record indicates that three days after his in-service car accident he reported neck pain and was even diagnosed with a neck strain. As such, the VA medical opinion is based on an inaccurate factual premise. Accordingly, the Board must remand for another medical opinion as the April 2018 VA opinion is inadequate for VA ratings purposes. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (holding that medical opinions based on incomplete or inaccurate factual premises are not probative). The matter is remanded for the following actions: 1. Acquire a VA addendum opinion as to the nature and etiology of the Veteran's diagnosed cervical spine and/or neck disability. The examiner is ordered to review the evidence outlined in this decision and the evidence of record prior to answering the following question: Whether it is at least as likely as not (roughly a 50 percent probability or greater) the Veteran's current cervical spine and neck disorder is the result of active service? In answering this question, the examiner must expressly consider the following evidence: a. His January 1990 head injury. b. His September 12, 1990, diagnosis of a cervical strain three days after his in-service car accident. c. His lay statements of continued neck pain since service. Note: All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 2. After the above is completed in addition to any other development deemed necessary, readjudicate the Veteran's claim. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Law Clerk, Tyler R. Masters 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.