Citation Nr: 22017272 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 17-50 244A DATE: March 24, 2022 REMANDED Entitlement to service connection for a cervical spine disability, to include as secondary to the Veteran's bilateral degenerative joint disease of the shoulders, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Coast Guard from June 1996 to April 2012. This case comes before the Board of Veterans' Appeals (Board) on appeal of an April 2016 decision by a Department of Veterans Affairs (VA) Regional Office (RO). This case was remanded by the Board in February 2020 so that the Veteran could be an afforded a VA examination in order to determine the nature and etiology of his claimed cervical spine disability. That examination has been completed; the Board will now proceed to decide this cased based on the evidence of record. The Board finds that additional development is required before the claim on appeal is decided. The Veteran contends that his currently diagnosed cervical spine disability is either related to his service or his service-connected conditions. The Veteran believes that his cervical spine disability was caused by a training exercise in the Coast Guard where his motor board fell of the back of a 15-foot wave. Alternatively, the Veteran asserts that his cervical spine disability is either caused or aggravated by his service-connected bilateral shoulder degenerative joint disease (DJD). The Veteran was afforded a VA examination in July 2020. At that time, the Veteran complained of constant pain in the back of the neck with radiation to both shoulders. The Veteran further reported issues with dexterity in his hands as well as tingling in both arms including his shoulders and elbows. The Veteran exhibited a decreased range of motion of the neck with pain resulting in functional loss. The examiner diagnosed the Veteran with intervertebral disc syndrome (IVDS), degenerative disc disease (DDD), and radiculopathy of the left upper extremity. The July 2020 VA examiner opined that the Veteran's currently diagnosed cervical spine disability was less likely than not incurred in or caused by his service. In support of this conclusion, the examiner commented that the Veteran's service treatment records were silent for complaints of neck pain. The examiner explained that while the Veteran complained of tingling in his arms during service, this is attributable to his service-connected carpal tunnel syndrome and not his current cervical spine disability. Additionally, the pain that the Veteran complained of in 2007 is due to acute arthritis of his shoulder and not a cervical spine disability. The Board finds that the July 2020 opinion is inadequate to adjudicate the issue. In this regard, the examiner did not provide adequate rationale explaining why the Veteran's current cervical spine disability is not related to service. Nieves-Rodriguez v. Peake, supra. Moreover, the examiner did not address the Veteran's assertion his current cervical spine disability is related to an in-service accident in which the Veteran fell off of a motor board. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination was inadequate where the examiner did not comment on a Veteran's reports of in-service injury and instead relied on the absence of evidence in a Veteran's service treatment records to provide a negative opinion). Therefore, the Board finds that an additional medical opinion is warranted to address the nature and etiology of his cervical spine disability. The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Obtain an etiology opinion from an appropriate examiner to determine the nature and etiology of the Veteran's cervical spine disability. The need for a physical examination or telehealth evaluation is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review, and the examiner should indicate that the record was reviewed in connection with the examination. All indicated tests and studies should be accomplished and the findings then reported in detail. Based on the review of the record, the examiner must provide an opinion as to the following: (A) Is it at least as likely as not (50 percent or better probability) that any currently present cervical spine disability, to include a IVD and degenerative disc disease, had its onset during his active service, or is otherwise etiologically related to such service? (B) Is it at least as likely as not (50 percent or better probability) that any currently present cervical spine disability, to include a IVD and degenerative disc disease, was caused OR aggravated by his service connected bilateral shoulder disabilities? The examiner must consider the Veteran's lay statements regarding the onset and continuity of his symptoms. The examiner must specifically address the Veteran's contention that his cervical spine disability is related to an in-service training exercise in the Coast Guard where his motor board fell of the back of a 15-foot wave. A complete rationale should be given for each opinion expressed. In this regard, a discussion of the facts and medical principles involved would be considerable assistance Christopher J. O'Donnell Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Baronofsky 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.