Citation Nr: 22041368 Decision Date: 07/19/22 Archive Date: 07/19/22 DOCKET NO. 17-08 447 DATE: July 19, 2022 REMANDED Entitlement to service connection for neurological disability, to include ulnar neuritis, carpal tunnel syndrome, central neurological dysfunction, and autonomic nerve disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty in the Navy from May 1969 to May 1973, including combat service for which he was awarded the Combat Action Ribbon. This matter is on appeal before the Board of Veterans Appeals (Board) from an October 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In December 2018, the case was remanded for further development. In December 2021, a Board hearing was held before the undersigned; a transcript of the hearing is of record. The previous Board remand characterized the issue on appeal as entitlement to service connection for bilateral neuritis of the ulnar nerve. However, in his initial January 2013 claim, the Veteran indicated that he was seeking service connection for "neurological issues." The October 2013 rating decision then denied service connection for neuritis of the ulnar nerve, claimed as neurological issues. Also, in an April 2013 medical opinion, a private treating physician indicated that the Veteran could have a central neurological dysfunction, noting his reporting of numerous systemic symptoms. Additionally, in a statement received in May 2020, the Veteran indicated that VA had misinterpreted his claim for neurological issues and that the claim is actually centered on him having peripheral neuropathy and autonomic nerve disorder caused by exposure to toxins during service. Moreover, a March 2020 VA primary care record does note that the Veteran had been receiving treatment for idiopathic peripheral neuropathy. Given this combination of medical evidence and contentions, the Board has found it appropriate to recharacterize the issue on appeal as listed above. See e.g., Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Entitlement to service connection for neurological disability, to include ulnar neuritis, carpal tunnel syndrome, central neurological dysfunction, and autonomic nerve disorder, is remanded. The Veteran has alleged that his current neurological disability is related to chemical exposures, including exposure to lead, during service from his duties as a Boiler Technician. Pursuant to the December 2018 remand, the Veteran was afforded a VA examination in December 2019. The examiner diagnosed the Veteran with bilateral neuritis of the ulnar nerve and remote history of carpal tunnel syndrome of the bilateral upper extremities, status post repair, with residual right sensorimotor median neuropathy. The examiner then opined that the Veteran's right upper extremity neurological disability was a post-service condition likely caused by post-service activity. In so doing, the examiner noted that the there was no indication in the medical literature that the chemicals to which the Veteran was exposed during service tended to cause median or ulnar neuropathy. The examiner also indicated that there was no evidence of neuritis or exam findings compatible with neuritis during service or until years thereafter and in the interim, the Veteran worked as a tool and dye maker for 30 years likely requiring dexterity and strength in the upper extremities in repetitive tasks of a much longer duration compared with working a few years during active duty as a boiler technician. As indicated above, the Veteran was noted to have idiopathic peripheral neuropathy by the VA primary care physician in March 2020. Also, as indicated above, the examiner appeared to find that the Veteran's symptoms of neuropathy did not appear until after his 30-year history of working as a tool and dye maker. However, the first medical evidence of record indicative of a neuropathy is from 1987, approximately 14 years after service, with the Veteran reporting at that time an approximate 5-year history of carpal tunnel syndrome. Given these inconsistencies between the VA examiner's findings and the Veteran's medical history and the medical literature, a remand is appropriate so that a supplemental medical opinion may be provided. This opinion should address the Veteran's broader assertions of a systemic neurological disability (i.e., central nervous dysfunction and/or autonomic nerve disorder) related to chemical exposure during service, along with ulnar and median nerve symptomatology noted by the December 2019 VA examiner and the peripheral neuropathy noted in March 2020. Prior to arranging for the opinion, the agency of original jurisdiction (AOJ) should obtain updated VA treatment records dated from February 2021 to the present. The matter is REMANDED for the following action: 1. Obtain updated VA treatment records dated from February 2021 to the present. 2. Thereafter, arrange for a supplemental opinion by an appropriate clinician addressing the likely etiology of any current neurological disability, to include ulnar neuritis, carpal tunnel syndrome, central neurological dysfunction and/or autonomic nerve disorder. The examiner should review the claims file in conjunction with the examination. This review should include: The service treatment records, including the April 1973 separation examination. It should also include the VA treatment records, including a June 2013 neurology visit, a June 2013 EMG consultation, a September 2013 physical medicine note, a March 2019 neurology visit, a May 2019 neurology visit, a June 2019 VA EMG testing report, a July 2019 neurology visit, an August 2019 rheumatology consultation, an August 2019 VA neurology note (pertaining to the results of rheumatological testing), the March 2020 VA primary care visit noting idiopathic peripheral neuropathy; and any other VA treatment records deemed pertinent. Additionally, the review should include the post-service private treatment records (to the extent available), including January 1987 EMG testing, January 1987 carpal tunnel release operative reports: October 1988 medical visit showing evaluation for increasing pain in the wrists due to new job duties; January 1992 visit noting elbow fracture; March 1992 visit noting that the elbow fracture was well healed; and any other private post-service medical records deemed pertinent. Moreover, the review should include a February 2013 statement from the Veteran's fellow servicemember, reporting on the nature of chemical exposures during service (if available); the April 2013 letter from the private physician (if available), indicating that she could easily see a correlation between the Veteran's long list of symptoms and a central neurological dysfunction that could absolutely be explained by his exposure to a multitude of noxious and chemicals during his military service; a fact sheet from the New Jersey Department of Health Services, which the Veteran annotated with information concerning his chemical exposures aboard ship (if available); a November 2018 VA mental disorder examination with MMPI test results pertaining to the Veteran's somatic complaints; the December 2019 VA examination with accompanying December 2019 medical opinion; the Veteran's April 2020 statement (if available) indicating that he was actually claiming that he had both peripheral neuropathy and autonomic nerve disorders caused by environmental exposures in service; and the Veteran's December 2021 Board hearing testimony (if available). The clinician should also review applicable medical literature, including literature pertaining to the relationship between peripheral neuropathy and lead and other chemical exposures. The clinician should then provide medical opinions in answer to the following questions: A) Does the evidence indicate that the Veteran suffers from a current central nervous dysfunction? B) If the evidence indicates that the Veteran's suffers from a current central nervous dysfunction, is it at least as likely as not that this dysfunction is related to service, including chemical exposures therein? C) Does the evidence indicate that the Veteran suffers from an autonomic nerve disorder? D) If the evidence indicates that the Veteran's suffers from a current autonomic nerve disorder, is it at least as likely as not that this disorder is related to service, including chemical exposures therein? E) Is it at least as likely as not that current peripheral neuropathy, including that identified by the March 2020 primary care physician, is related to the Veteran's service, including exposure to lead and other chemicals therein? F) Is it at least as likely as not that current ulnar neuritis, including that identified by the December 2019 VA examiner, is related to the Veteran's service, including exposure to lead and other chemicals therein? G) Is it at least as likely as not that current median nerve impairment/carpal tunnel syndrome, including that identified by the December 2019 VA examiner, is related to the Veteran's service, including exposure to lead and other chemicals therein? H) Is it at least as likely as not that any other current neurological disability is related to the Veteran's service, including exposure to lead and other chemicals therein? The clinician should explain the rationale for each opinion provided. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dan Brook, 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.