Citation Nr: 22018253 Decision Date: 03/28/22 Archive Date: 03/28/22 DOCKET NO. 17-29 521 DATE: March 28, 2022 REMANDED Entitlement to service connection for cervical spine disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1986 to December 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In November 2021, the Veteran testified, sitting in Alabama, before the undersigned via a virtual hearing. A transcript of the hearing has been associated with the virtual file and reviewed. The Board has broadened and recharacterized the claim of service connection for spine damage (cervical spondylosis) as entitlement to service connection for a cervical spine disorder. Entitlement to service connection for cervical spine condition is remanded. The Veteran contends that the onset of his cervical spine condition occurred during or is otherwise related to his period of active service. During a November 2021 Board hearing, the Veteran testified that he incurred several injuries during active service, to include dropping a weight on his shoulder in the 1990s, getting rear-ended in May 2005 and August 2005, and getting injured while ripping carpet during emergency assistance after a hurricane in September 1990. The Veteran reported that the pain from the injuries have persisted continuously since and that he has sought medical treatment for back pain on more than 70 occasions. The Veteran testified that he was referred to a specialized clinician, who diagnosed the cervical spine disorder. This specialist informed the Veteran that some symptoms were misattributed to his carpal tunnel diagnosis and are actually related to his cervical spine condition. Additionally, the Veteran's cervical spine condition resulted in some of his lower back symptoms (the Veteran is service-connected for low back strain), which resolved after receiving treatment for his cervical spine. 11/08/2021, Hearing Transcript. The Veteran's testimony is largely corroborated by the record. The service treatment records reveal that he injured his right shoulder in 1994. 07/24/2015, STR Medical, page 6. The Veteran sought treatment for back and shoulder pain on multiple occasions throughout his period of active service. See e.g., 07/24/2015, STR Medical, pages 5, 14 & 47. The Veteran was also diagnosed with carpal tunnel syndrome before separation from active service. 07/24/2015, STR Medical, page 24. The private treatment records also reveal that the Veteran was referred to a specialist after numerous complaints of pain in his wrists and back. Those carpal tunnel symptoms were later attributed to his cervical spine condition and was treated with epidural steroid injections. The Veteran was diagnosed with cevericalgia and cervical radiculopathy. 11/12/2021, Medical Treatment Record Non-Government Facility, at 53. A September 2015 VA examination noted a degenerative cervical spine condition was revealed by MRI imaging conducted in July 2014. The examiner opined that the Veteran's cervical spine condition is less likely than not related to his active service. However, the rationale is based on a finding that there is no evidence of a cervical spine injury during active service. However, the examiner did not have an opportunity to consider the Veteran's hearing testimony and private treatment records that were subsequently associated with the claims file. Specifically, the examiner did not explicitly consider whether the symptoms of the Veteran's cervical spine condition were misattributed to a different condition during active service. 09/01/2015, C&P Exam. Accordingly, the Board finds the September 2015 VA examination to be incomplete, and that an addendum medical opinion is warranted before an adjudication on merits. This matter is REMANDED for the following actions: 1. Obtain any outstanding VA treatment records. Additionally, request the Veteran to submit any relevant private treatment reports or provide VA with authorization to obtain any such records. 2. After completing directive # 1, schedule the Veteran for a VA examination with an appropriate clinician to determine the nature and etiology of any cervical spine condition. The clinician is to review the virtual file, including a copy of this Remand, to become familiar with the Veteran's relevant medical history. Then: (a.) The clinician is to provide an opinion whether any current cervical spine condition is at least as likely as not related to an in-service injury, event, or disease. See 07/24/2015, STR Medical, page 5, 6, 14, 24, and 47 (note: records are in multiple different files with the same date). The clinician is to note and consider that at the November 2021 Board hearing the Veteran testified that treatment for his cervical spine condition has resolved some of his lower back symptoms. See 11/08/2021, Hearing Transcript. Additionally, the clinician is to consider the treatment records indicating that symptoms were previously attributed to his carpal tunnel diagnosis have since been attributed to his cervical spine condition. See 11/12/2021, Medical Treatment Record Non-Government Facility, page 36. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board David Han 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.