Citation Nr: 22016552 Decision Date: 03/22/22 Archive Date: 03/22/22 DOCKET NO. 16-36 766 DATE: March 22, 2022 REMANDED Entitlement to service connection for a cervical spine disability is remanded. REASONS FOR REMAND The Veteran served honorably in the United States Air Force from October 1979 to September 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston Salem, North Carolina. The Veteran testified before the Board at an October 2021 virtual hearing. A transcript has been associated with the claims file. Entitlement to service connection for a cervical spine disability is remanded. Although the Veteran underwent a VA examination in January 2013 in connection with his claim for service connection, that examination does not adequately address all open medical questions raised by the Veteran. Moreover, the facts before the examiner do not reflect the Veteran's complete medical record of care. The Veteran should be afforded a new examination so that an examiner can provide full consideration to the Veteran's contentions based on a complete record. The Veteran contended in his February 2013 Notice of Disagreement (NOD) that his "low back pain (cervical spine degenerative)" came from sleeping in a field and carrying military equipment, and that during the night, he experiences intense pain in his lower back. Also in his NOD, the Veteran identified potentially relevant treatment records from February 1979 that could be related to his cervical spine; attempts to locate such records should be made on remand. On his May 2019 Form 9, the Veteran contended that cumulative trauma to his head and neck resulted in degenerative changes to the C5-C6 vertebral region, which was identified in a February 2004 CT scan. He contended that his use of painkillers for other conditions masked his neck pain. The Veteran contended that the following specific incidents, as documented in his service treatment records, contributed to his degenerative changes in his cervical spine: (1) head trauma as a result of a collision with a door, resulting in a laceration to his forehead in July 1980; (2) headaches beginning in October 1981; (2) head trauma as a result of being hit in the right eye with an elbow, resulting in a laceration to his right eyebrow and blurred vision, in July 1982; (3) head trauma/eye injury, as a result of being hit with a finger in his right eye, in October 1982; (4) head trauma, resulting in stitches, as a result of being hit in the head with a steel beam in May 1983; (5) head trauma, resulting in a laceration above the left eyebrow in August 1987; and (6) continuation of headaches in February 1994. See 2019 VA Form 9 (consolidated for redundancy and inaccuracies after reviewing service treatment records and 2004 CT scan). The Board, on its own initiative, notes that the Veteran's service treatment records also show: (7) a blow to the right side of the Veteran's face in May 1981 and (8) a headache in 1992. Additionally, in regard to specific incidents of cumulative trauma, the Veteran has contended that in approximately 1988 or 1989 he was involved in a rear-end collision accident, and that he was in a second car accident in 1999, when he was hit by another driver. He contends that he has experienced symptoms continuously, both in service and following service. The Veteran's wife, a licensed practical physical therapy assistant, testified that the Veteran experienced symptoms of neck tightness, pain, muscle spasms, and reduced range of motion, and that these symptoms were present in service and progressively worsened over the course of his service. See October 2021 Board Hearing Transcript. During his hearing, the Veteran alluded to the potential for there to be outstanding private treatment records, which may not have been associated with the Veteran's claims file; on remand he should be afforded an opportunity to identify any such records. See October 2021 Board Hearing Transcript. The matters are REMANDED for the following action: 1. Provide the Veteran and his representative an opportunity to identify and submit, or authorize VA to obtain on the Veteran's behalf, any outstanding private treatment records related to treatment he has received for his cervical spine, including treatment records from February 1979, identified by the Veteran in his February 2013 Notice of Disagreement. 2. Schedule the Veteran for a cervical spine examination. The examiner must review the claims file and a copy of this Remand. The examiner is asked to respond to the following: (a.) Is it at least as likely as not (approximately 50 percent probability) that the Veteran's cervical spine disability, to include the C5-C6 degenerative changes identified in his February 2004 CT scan, had onset during, or is otherwise related to, his active duty service? In offering any opinion, the examiner must acknowledge and consider the contentions raised by the Veteran, which include an assertion that cumulative trauma from/evidenced by the following incidents caused the Veteran to develop degenerative changes in his cervical spine which were masked by the use of painkillers for other conditions: i. head trauma as a result of a collision with a door, resulting in a laceration to his forehead in July 1980; ii. headaches beginning in October 1981; iii. head trauma as a result of being hit in the right eye with an elbow, resulting in a laceration to his right eyebrow and blurred vision, in July 1982; iv. head trauma/eye injury, as a result of being hit with a finger in his right eye, in October 1982; v. head trauma, resulting in stitches, as a result of being hit in the head with a steel beam in May 1983; vi. head trauma, resulting in a laceration above the left eyebrow in August 1987; vii. continuation of headaches in February 1994; viii. a blow to the right side of the Veteran's face in May 1981; ix. a headache in 1992; x. an undocumented rear-end collision accident in approximately 1988 or 1989; xi. an undocumented car accident in 1999, when he was hit by another driver. The examiner should also address the contention that made by the Veteran on his February 2013 NOD, stating his "low back pain (cervical spine degenerative)" came from sleeping in a field and carrying military equipment and that during the night, he experiences intense pain in his lower back. The examiner should consider the lay testimony from the Veteran that he has experienced neck pain throughout service and continually thereafter, as well as the October 2021 Board hearing testimony from the Veteran's spouse (a licensed practical physical therapy assistant) regarding her observations of the Veteran's progressively worsening neck pain, beginning in service and continuing to the present. 3. Thereafter, and after any additional development deemed necessary, readjudicate the claim. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Hennessy, 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.