Citation Nr: 23016366 Decision Date: 03/17/23 Archive Date: 03/17/23 DOCKET NO. 91-50 821 DATE: March 17, 2023 ORDER Entitlement to an initial disability rating in excess of 10 percent prior to September 26, 2003, for cervical spine whiplash injury with subluxation of C3-4 is denied. Entitlement to a 20 percent disability rating from September 26, 2003, for cervical spine whiplash injury with subluxation of C3-4 is granted. Entitlement to service connection for radiculopathy of the bilateral upper extremities, as secondary to cervical spine whiplash injury with subluxation of C3-4, is granted. REMANDED Entitlement to service connection for quadriparesis, to include as secondary to service-connected cervical and/or thoracolumbar spine disabilities, is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. Prior to September 23, 2006, the Veteran's cervical spine whiplash injury with subluxation of C3-4 was manifested by mild intervertebral disc syndrome (IVDS). 2. From September 23, 2006, the Veteran's cervical spine whiplash injury with subluxation of C3-4 is manifested by forward flexion of the cervical spine limited to, at worse, 20 degrees. 3. The Veteran has radiculopathy of the bilateral upper extremities proximately due to or the result of his service-connected cervical spine whiplash injury with subluxation of C3-4. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent prior to September 26, 2003, for cervical spine whiplash injury with subluxation of C3-4 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5243, 5293. 2. The criteria for a 20 percent rating for cervical spine whiplash injury with subluxation of C3-4 have been met, effective September 26, 2003. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5243. 3. The criteria for entitlement to service connection for radiculopathy of the bilateral upper extremities, as secondary to service-connected cervical spine whiplash injury with subluxation of C3-4 have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from June 1972 to May 1979. He had subsequent service in the Marine Corps Reserve from May 1979 to September 1987, including periods of active duty for training (ACDUTRA) as follows: from June 5, 1980 to June 6, 1980; June 16, 1980 to June 29, 1980; May 4, 1981 to May 17, 1981; September 21, 1981 to October 4, 1981; August 21, 1983 to September 3, 1983; August 2, 1984 to August 18, 1984; May 4, 1985 to May 18, 1985; June 21, 1986 to July 5, 1986; and October 13, 1986 to November 26, 1986. This case has a lengthy and complex procedural history that has been explained in detail in prior Board decisions and will not be recounted in detail here. Most recently, this case was before the Board in October 2020, at which time the above noted issues were remanded for further development. During the Veteran's appeal for entitlement to an increased rating for a cervical spine disability, the Board notes that the Veteran has not submitted a formal claim for secondary service connection for radiculopathy of the bilateral upper extremities. Regardless, the Board finds that the issues of secondary service connection for radiculopathy of the bilateral upper extremities have been reasonably raised by the evidence of record. See Bailey v. Wilkie, 33 Vet. App. 188, 201-03 (2021) (38 C.F.R. § 3.155(d)(2) provides that once VA receives a complete claim, it must adjudicate as part of the claim entitlement to any ancillary benefits and additional benefits for "complications" of the claimed disability, including those identified by the Rating Schedule). In fact, in a case factually like the instant Veteran's case, the Court held that VA is obligated to identify, develop, and adjudicate claims for secondary service connection that are reasonably raised during the processing of a properly initiated claim as to the primary service-connected disability's evaluation level (within an IR claim), such as complications of the primary service-connected disability or those claims that "logically relate" to same. Wilson v. McDonough, 35 Vet. App. 103, 110 (2022). To this end, in considering all lay and medical evidence of record as instructed by the provisions of 38 C.F.R. § 3.155(d)(2), the Board sees that the September 2011 VA examiner diagnosed the Veteran with cervical radiculopathy in both upper extremities, resulting from his service-connected cervical spine disability on appeal. Therefore, the issue of entitlement to service connection for cervical radiculopathy in bilateral upper extremities has been reasonably raised within the scope of the pending increased rating claim for the cervical spine. Moreover, the Board is cognizant that under the General Rating Formula for Diseases and Injuries of the Spine, VA regulation instructs that associated objective neurologic abnormalities should be evaluated separately under an appropriate diagnostic code. See 38 C.F.R. § 4.71a, Note (1) (Diagnostic Codes 5235 to 5243). Therefore, the issue of entitlement to service connection for radiculopathy of the bilateral upper extremities has been added to the present appeal, even in the absence of explicit AOJ adjudication of same. Increased Rating 1. Entitlement to an increased disability rating for cervical spine disability As a preliminary matter, the Board notes that the Veteran did not appear for a VA examination that was scheduled pursuant to the October 2020 Board remand. Notably, the Veteran was scheduled for a VA cervical spine examination in July 2021. See Exam Request, dated April 1, 2021. A July 2021 VA Form 27-0820, Report of General Information, notes that the Veteran was requesting to reschedule a VA examination scheduled for July 23, 2021. The examination was subsequently rescheduled for March 2, 2022. An examination request notes that VA was unable to contact the Veteran. See Exam Request, dated March 3, 2022. VA contacted the Veteran via letter in March 2022 regarding his failure to appear and future availability for examination. See Subsequent Development Letter, dated March 4, 2022. A March 2022 VA Form 27-0820 notes that the Veteran missed the examination because he was getting other testing done and requested to reschedule examination for the second week of August 2022 or any time thereafter. The examination was subsequently rescheduled for September 6, 2022. An examination request notes that the Veteran was unavailable. See Exam Request, dated September 6, 2022. A September 2022 VA Form 27-0820 notes that the Veteran could not attend the exam because he needed more time to contact his private doctors for evidence to support his claim. The Veteran stated that he would attend the rescheduled exam. The examination was rescheduled for October 12, 2022. An examination request notes that the Veteran was unavailable. See Exam Request, dated October 12, 2022. VA contacted the Veteran via letter in November 2022 regarding his failure to appear for the October 2022 examination. The correspondence encouraged the Veteran to respond within 30 days or a decision may be made on his claim. See Subsequent Development Letter, dated November 18, 2022. To date, no response has been received. The Veteran has not provided a statement reflecting good cause for not appearing for the most recently rescheduled examination, nor has he requested that another VA examination be scheduled since that time. Veterans have an obligation to assist in the adjudication of their claim, see Wood v. Derwinski, 1 Vet. App. 190, 193 (1991), and individuals for whom examinations have been authorized and scheduled are required to report for same. See 38 C.F.R. § 3.326. When a veteran, without good cause, does not report for an examination scheduled in conjunction with an original compensation claim, the claim shall be rated based on the evidence of record. 38 C.F.R. § 3.655(b). Considering the foregoing, the Board concludes that good cause has not been shown as to why the Veteran did not attend the VA examination and will decide the appeal based on the evidence of record. Disability ratings are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Consideration must be given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection is required. Fenderson v. West, 12 Vet. App.119, 126 (1999). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the claim on appeal. Hart v. Mansfield, 21 Vet. App.505 (2007). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. Although pain may cause a functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,' in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). The Veteran is assigned a 10 percent rating, effective November 28, 1988, under DC 5299-5293. He is assigned a 20 percent rating, effective September 22, 2011, under DC 5299-5243. Hyphenated Diagnostic Codes are used when a rating under one Diagnostic Code requires use of an additional Diagnostic Code to identify the basis for the evaluation assigned. See 38 C.F.R. § 4.27. The provisions of 38 C.F.R. § 4.27 provide that unlisted disabilities requiring rating by analogy will be coded with the first two numbers of the schedule provisions for the most closely related body part and 99. Here, the hyphenated diagnostic code indicates that the Veteran's cervical spine disability is rated as analogous to a spinal disorder (Diagnostic Code 5299) under the criteria for intervertebral disc syndrome. 38 C.F.R. § 4.71a. The Board observes that, during this appeal, rating criteria governing the evaluation of spine disabilities were revised effective September 23, 2002, and September 26, 2003. In this regard, the Board notes that VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the Veteran. As such, VA must consider the claim pursuant to the former and revised regulations during this appeal. See VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. Under the rating criteria for intervertebral disc syndrome (IVDS) in effect prior to September 23, 2002, a 10 percent rating was warranted for mild IVDS. A 20 percent rating was warranted for moderate IVDS manifested by recurring attacks. A 40 percent rating was warranted for severe IVDS manifested by recurring attacks with intermittent relief. A 60 percent rating was warranted for pronounced IVDS with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurologic findings appropriate to site of diseased disc and little intermittent relief. 38 C.F.R. § 4.71a, DC 5293. The Board notes that symptoms contemplated under DC 5293 encompass both orthopedic and neurological findings. As revised effective September 23, 2002, DC 5293 states that intervertebral disc syndrome is to be evaluated either based on the total duration of incapacitating episodes over the past 12 months, or, in the alternative, by combining under 38 C.F.R. § 4.25 the separate evaluations of its chronic orthopedic and neurologic manifestations along with evaluations for all other disabilities, whichever method results in the higher evaluation. Under DC 5293, from September 23, 2002, until September 26, 2003, a 10 percent evaluation is warranted for intervertebral disc syndrome where the evidence shows incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating applies where there are incapacitating episodes having a total duration of at least two weeks, but less than four weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the last 12 months. A 60 percent rating is warranted where the evidence reveals incapacitating episodes having a total duration of at least six weeks during the past 12 months. Note (1) to this version of DC 5293 defines an incapacitating episode as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Chronic orthopedic and neurological manifestations are defined as orthopedic and neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so. Note (2) provides that when evaluating on the basis of chronic manifestations, evaluate orthopedic disabilities using evaluation criteria for the most appropriate orthopedic diagnostic code or codes. Neurological disabilities are to be evaluated separately using evaluation criteria for the most appropriate neurological diagnostic code or codes. 38 C.F.R. § 4.71a, DC 5293 (2002). The regulation for rating intervertebral disc syndrome based on incapacitating episodes was slightly revised again in September 2003, during which DC 5293 was renumbered and amended as the current DC 5243. Effective September 26, 2003, the amended criteria provide that IVDS can be evaluated under the General Rating Formula for Diseases and Injuries of the Spine or the Formula for Rating IVDS Based on Incapacitating Episodes, whichever results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, DC 5243. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended again, effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). While portions of the rating schedule addressing the musculoskeletal system were revised, DC 5243 was not significantly changed. Specifically, the rating criteria itself was unchanged; however, DC 5243 was amended to clarify that this diagnostic code should only assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root. Under the Formula for Rating IVDS, a 10 percent rating is warranted with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is warranted with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is warranted with incapacitating episodes having a total duration of at least 6 months. Under the General Rating Formula, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or the combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted for forward flexion of the cervical spine 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Ankylosis is complete immobility of the joint in a fixed position, either favorable or unfavorable. See Dinsay v. Brown, 9 Vet. App. 79, 81 (1996); Lewis v. Derwinski, 3 Vet. App. 259 (1992). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. 38 C.F.R. § 4.71a, Note (5). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. Under the rating schedule, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion for the thoracolumbar spine is 240 degrees. Id. at Note (2). The criteria under the General Rating Formula for Diseases and Injuries of the Spine are to be applied with or without symptoms of pain (whether or not it radiates), aching, or stiffness in the area of the spine involved. 38 C.F.R. § 4.71a. The criteria under the General Rating Formula for Diseases and Injuries of the Spine are to be applied with or without symptoms of pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. 38 C.F.R. § 4.71a. Turning to the evidence, a February 1990 medical report indicates there was tenderness to palpation in the cervical spine area; however, the tenderness was diffuse. A March 1990 radiology consultation report revealed the cervical vertebral bodies, their appendages, and the intervertebral disc spaces appeared intact. The intervertebral foramina appeared patent. There was no evidence of prevertebral soft tissue swelling was noted. There was straightening of the cervical lordosis. The Veteran appeared for a VA examination in July 1990. The physician noted a normal electromyography (EMG) report and normal somatosensory evoked potential (SSEP) report. At the time of examination, he had flat affect. Fundi, fields, and extraocular movement were normal. There was no evidence of nystagmus. There was mild motor weakness in the upper extremities with some giving way. The Veteran was unable to move his lower extremities at all and he had no sensation below the neck. Cerebellar function was normal. The Veteran appeared for a VA spine examination in June 2002. The examiner noted that the Veteran was wearing a cervical collar which was removed for examination. Range of motion of the cervical spine from neutral position showed flexion to 20 degrees, with 0 degrees of extension. There was approximately 10 to 15 degrees of rotation from neutral. There was no actual spine or paravertebral tenderness. The Veteran was able to support his head in a neutral position without the cervical collar. The Veteran appeared for a VA neck conditions examination in September 2011. The Veteran reported persistent pain at and above the level of the thoracic spine. He reported flare-ups that impacted the function of his cervical spine described in his own words as limiting his ability to work on something to working on his computer for more than two to three hours which precipitates spasms. He reported having to take 10-to-15-minute rests if typing more than 15 minutes at a time. He reported having to take antispasmodics. His spasms caused him to knock a glass over or not be able to pick it up. He also reported an inability to hold onto toilet paper during spasms. Range of motion testing revealed forward flexion ended at 30 degrees; extension ended at 20 degrees; right lateral flexion ended at 35 degrees, with painful motion beginning at 30 degrees; left lateral flexion ended at 30 degrees, with painful motion beginning at 30 degrees; right lateral rotation ended at 40 degrees; and left lateral rotation ended at 45 degrees. The Veteran was able to perform repetitive-use testing with three repetitions with additional limitation in range of motion. Post-test range of motion revealed forward flexion ended at 30 degrees; extension ended at 15 degrees; right lateral flexion ended at 35 degrees; left lateral flexion ended at 30 degrees; right lateral rotation ended at 40 degrees; and left lateral rotation ended at 50 degrees. Contributing factors of functional loss and/or functional impairment after repetitive use included less movement than normal and pain on movement. Localized tenderness or pain on palpation was observed in the cervical spine. Guarding or muscle spasm was present, but it did not result in abnormal gait or spinal contour. Muscle strength testing revealed active movement against some resistance in elbow flexion and extension, as well as wrist flexion and extension. Active movement against gravity was observed in finger flexion and extension. Muscle atrophy was not present. Reflex examination revealed hypoactive reflexes bilaterally in the biceps, triceps, and brachioradialis. Sensory exam revealed decreased sensation to light touch bilaterally in the shoulder area, inner/outer forearm, and hand/fingers. Signs or symptoms due to radiculopathy included severe intermittent pain, paresthesias and/or dysesthesias, and numbness. Upper, middle and lower radicular groups were the involved nerve roots. Severe radiculopathy was noted bilaterally. Other neurological abnormalities included quadriplegia, for which he required the constant use of a wheelchair. A cervical spine magnetic resonance imaging (MRI) from September 2011 showed a mild central bulge of the C3-4 discs with no evidence of spinal cord abnormalities. The alignment of the vertebral bodies was normal, and the heights of the vertebral bodies were maintained. The disc spaces were largely maintained as well. There was no evidence of instability with flexion and extension. The facet joints appeared normal. The odontoid view demonstrated normal symmetry of C1 and C2. The prevertebral soft issues were normal. After review of the competent medical evidence, the Board finds that the evidence is against finding that the Veteran's service-connected cervical spine whiplash injury with subluxation of C3-4 warrants a disability rating in excess of 10 percent for the period on appeal prior to September 26, 2003, regardless of which version of the diagnostic criteria is applied. In evaluating the Veteran's cervical spine disability under DC 5293 in effect prior to September 23, 2002, the Board notes that the available evidence of record fails to show that the Veteran's cervical spine disability manifested as moderate IVDS manifested by recurring attacks to be considered moderate IVDS, as contemplated by the 20 percent rating. Likewise, a higher rating under the criteria in effect from September 23, 2002, to September 26, 2003, under DC 5293 based upon the total duration of incapacitating episodes is not warranted, as the VA and private treatment records do not contain any indication that the Veteran's treating physicians prescribed bed rest for his cervical spine disability. The Board has considered combining the separate evaluations of the Veteran's chronic orthopedic and neurologic manifestations under 38 C.F.R. § 4.25, as directed by the IVDS criteria effective from September 23, 2002. However, the Board finds that there is no medical evidence of record that supports a finding that the Veteran's orthopedic nor neurological abnormalities are attributable to his cervical spine whiplash injury with subluxation of C3-4. However, the Board finds that the Veteran's disability picture more closely approximates a 20 percent disability rating from September 26, 2003, under the amended criteria for DC 5243. Specifically, at the time of the June 2002 VA examination, range of motion testing revealed forward flexion to 20 degrees. Thus, the Board will resolve the reasonable doubt in the Veteran's favor to conclude the criteria for a 20 percent disability rating are met from September 26, 2003, the date DC 5242 and the amended criteria for DC 5243 became effective. Although an increased 20 percent rating is warranted, the evidence of record does not reflect symptoms that would meet the criteria for a higher rating during the period on appeal from September 26, 2003. Specifically, the evidence fails to reflect that the Veteran's cervical spine has been limited to 15 degrees or less nor is there evidence of favorable ankylosis of the entire cervical spine. The evidence also fails to show any indication that the Veteran's treating physicians prescribed bed rest for his cervical spine disability. Without evidence of greater limitation of motion, favorable ankylosis of the entire cervical spine, or incapacitating episodes, a disability rating in excess of 20 percent for the period from September 26, 2003, is denied. In sum, for the reasons and bases expressed above, the Board has concluded that a disability rating in excess of 10 percent is not warranted for cervical spine whiplash injury with subluxation of C3-4 from prior to September 26, 2003, and a 20 percent disability rating, but no higher, is warranted from September 26, 2003. Service Connection 1. Entitlement to service connection for radiculopathy of the bilateral upper extremities Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. In order to prevail on a claim of service connection, generally, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b) (2020); Allen v. Brown, 8 Vet. App. 374 (1995). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen, supra. Upon review of the evidence of record, the Board grants the appeal as to entitlement to service connection for radiculopathy of the bilateral upper extremities as secondary to a service-connected cervical spine whiplash injury with subluxation of C3-4. Regarding secondary service connection, there is probative medical evidence of record indicating that the Veteran has radiculopathy of the bilateral upper extremities proximately due to or the result of his service-connected cervical spine whiplash injury with subluxation of C3-4. 38 C.F.R. § 3.310(a); Atencio v. O'Rourke, 30 Vet. App. 74, 90-91 (2018). In this regard, a September 2011 VA examiner diagnosed cervical radiculopathy in bilateral upper extremities. The upper, middle, and lower radicular groups were the involved nerve roots. The overall severity of the Veteran's radiculopathy of the bilateral upper extremities was noted to be "severe." Signs or symptoms due to radiculopathy included severe intermittent pain, paresthesias and/or dysesthesias, and numbness. Accordingly, secondary service connection for radiculopathy of the bilateral upper extremities is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310. REASONS FOR REMAND 1. Entitlement to service connection for quadriparesis In October 2020, the Board remanded the Veteran's claim of entitlement to service connection for quadriparesis. Notably, the Board instructed the RO to refer the VA claims file to a medical professional with appropriate expertise, other than the examiner who provided the September 2011 and September 2016 VA opinions, to provide an opinion as to the etiology of the Veteran's claimed quadriparesis. The Board notes that a VA medical opinion has not yet been obtained. As this request has not been complied with, the claim must be remanded again to obtain the necessary medical opinion. Stegall v. West, 11 Vet. App. 268 (1998). 2. Entitlement to a TDIU The issue of entitlement to a TDIU is inextricably intertwined with the service connection claim remanded herein, as any decision on that matter may affect entitlement to a TDIU. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). Moreover, because the implementation of the Board's grant of service connection for radiculopathy of the bilateral upper extremities, including the assigning of a disability rating and effective date, could significantly impact a decision on the issue of TDIU, the issues are inextricably intertwined. The matters are REMANDED for the following action: 1. Implement the Board's award of service connection for radiculopathy of the bilateral upper extremities, to include assigning initial disability rating(s) and effective date(s). 2. Refer the VA claims file to a neurologist or other appropriate specialist who specializes in spinal cord injuries, other than the examiner who provided the September 2011 and May 2016 VA opinions. The examiner is requested to review the claims file in its entirety, including all service treatment records, VA, and private treatment records. The examiner should then address the following: (a.) Is it at least as likely as not that the diagnosed quadriparesis was incurred in the Veteran's active-duty service or during a period of ACDUTRA? (b.) If not, is it at least as likely as not that the diagnosed quadriparesis was caused by the service-connected cervical and/or thoracolumbar spine disabilities? (c.) If not, is it at least as likely as not that the Veteran's diagnosed quadriparesis is aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by service-connected cervical and/or thoracolumbar spine disabilities? Should the examiner decide that a physical examination of the Veteran is required to address these questions, such should be scheduled. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that question(s). 3. Thereafter, the RO must review the requested medical opinion to ensure that it is responsive to and in compliance with the directives of this remand. If the opinion is deficient in any manner, implement corrective procedures. 4. After completing the above and all other development deemed necessary, adjudicate the claim of entitlement to a TDIU, to include referral for extraschedular consideration. D. SMART Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Tracy O. Joseph, 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.