Citation Nr: 22046809 Decision Date: 08/17/22 Archive Date: 08/17/22 DOCKET NO. 18-01 207 DATE: August 17, 2022 REMANDED Entitlement to service connection for cervical spondylosis is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1974 to August 1979 and from October 1982 to September 2003. In December 2019, the Veteran and his spouse testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In April 2020, this appeal was remanded for a VA medical opinion that addresses whether the Veteran's cervical spondylosis is related to his service. Regrettably, the Board finds another remand is warranted. Specifically, the Board finds that the May 2022 VA medical opinion is inadequate as it does not discuss the Veteran's in-service complaints of neck pain and of intermittent twitching in his neck. See Stegall v. West, 11 Vet. App. 268 (1998). In the May 2022 VA medical opinion, the VA examiner opines that the Veteran's cervical spondylosis is less likely than not incurred in or proximately due to service. The VA examiner notes that the Veteran reports an onset of neck pain during service in 1999, associated with being struck in the neck during a basketball game. The VA examiner notes that the Veteran's service treatment records are silent for subjective complaints, diagnosis, or treatment related to a cervical condition. Based on this finding, the VA examiner opines that a nexus cannot be established between the Veteran's current disability and his service. However, the Veteran's service treatment records reflect that in a January 2002 service treatment record, the Veteran was seen for soreness and pain in the right side of his neck. The assessment at that time was cervical radiculopathy. Physical therapy consult for neck exercise was recommended. See January 4, 2002, Walter Reed Army Medical center records. Also, in November 2002, the Veteran was seen for intermittent twitching in his neck occurring for multiple months. See November 1, 2002, service treatment records. Additionally, in an April 2003 report of medical assessment, the Veteran reports a twitch on the left side of his neck. See April 28, 2003, report of medical assessment. Given such, because the VA examiner did not consider these records, the Board finds that the VA medical opinion is inadequate. As such, a remand for an addendum opinion is warranted. The matters are REMANDED for the following action: 1. Request an addendum VA medical opinion from the May 2022 VA examiner, if the May 2022 VA examiner is not available, then from a qualified medical professional. After reviewing the entire record, the examiner should provide an opinion responding to the following: Whether the Veteran's cervical spondylosis is at least as likely as not (probability of 50 percent or greater) the result of a disease or injury incurred in or aggravated by service, to include the Veteran's in-service assessment of cervical radiculopathy. The VA examiner must discuss the Veteran's service treatment records that reflect neck pain, an assessment of cervical radiculopathy, and intermittent twitching. These records include the following: A) January 4, 2002, Walter Reed Army Medical Center record in which the Veteran was seen for soreness and pain in the right side of his neck. The assessment at that time was cervical radiculopathy. Physical therapy consult for neck exercise was recommended. B) November 1, 2002 service treatment record, in which the Veteran was seen for intermittent twitching in his neck occurring for multiple months. C) April 28, 2003, report of medical assessment, in which the Veteran reports a twitch on the left side of his neck. The examiner should discuss the Veteran's lay statements regarding the history and chronicity of symptomatology, to include the Veteran's statements that the onset of his neck pain began during service, and as continued since his separation from service. S/he should outline that history in the report. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, a reason for doing so must be provided. If the VA examiner relies on medical literature, please apply the medical literature to the specific facts of this case. It is insufficient to make a general statement such as "the medical literature does not support an association between cervical spondylosis and his service." Rather, the VA examiner must explain why the medical literature does not support such an association. If medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized. If utilizing references within the electronic claims file, the examiner should clearly provide an identifier. Any opinion expressed by the VA examiner must "contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). 2. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Abdelbary, 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.