Citation Nr: 9809204 Decision Date: 03/26/98 Archive Date: 04/14/98 DOCKET NO. 96-06 088 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Washington, DC THE ISSUES 1. Entitlement to benefits under 38 U.S.C. § 1151 for an atonic or neurogenic bladder as a result of surgery performed at a Department of Veterans Affairs facility in July 1992. 2. Entitlement to benefits under 38 U.S.C. § 1151 for additional left shoulder disability as a result of treatment at a Department of Veterans Affairs facility in October 1992. 3. Entitlement to benefits under 38 U.S.C.A. § 1151 for additional disability of the cervical spine as a result of surgery and treatment at a Department of Veterans Affairs facility in July and/or October 1992. 4. Entitlement to special monthly compensation based on the need for regular aid and attendance. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESS AT HEARINGS ON APPEAL The veteran ATTORNEY FOR THE BOARD S. J. Janec, Associate Counsel INTRODUCTION The veteran had active military service in the United States Marines Corps from November 1965 to April 1969. This matter comes before the Board of Veterans' Appeals (Board) from a April 1995 rating decision of the Washington, D.C. Regional Office (RO) of the Department of Veterans Affairs (VA) which denied benefits under 38 U.S.C.A. § 1151 for an atonic or neurogenic bladder, residuals of a urethral injury, residuals of a tonic clonic seizure, residuals of a left shoulder injury, and increased disability of the cervical spine as a result of surgery or treatment at a VA facility in 1992. These determinations were confirmed by the RO in a May 1995 rating decision, which also denied a temporary total rating based on a period of hospitalization and a total rating based on individual unemployability due to service connected disabilities. The veteran testified at a personal hearing in November 1996. The hearing officer confirmed the denial of the 38 U.S.C.A. § 1151 claims and also denied entitlement to special monthly compensation based on the need for aid and attendance. The veteran was informed of this determination in an April 1997 supplemental statement of the case. Another supplemental statement of the case was issued in October 1997. In November 1991, in another case, the United States Court of Veterans Appeals (Court) invalidated 38 C.F.R. § 3.358(c)(3), on which the Board based its decision, and remanded the case to the Board for further proceedings. Gardner v. Derwinski, 1 Vet. App. 584 (1991). The Court’s decision was affirmed by the United States Court of Appeals for the Federal Circuit (Court of Appeals) in Gardner v. Brown, 5 F.3d 1456 (Fed. Cir. 1993), and subsequently appealed to the United States Supreme Court (Supreme Court). On December 12, 1994, the Supreme Court issued its decision, affirming the decisions of the Court and the Court of Appeals. Brown v. Gardner, __ U.S. __, 115 S.Ct. 552 (1994). The Secretary of Veterans Affairs (Secretary) sought an opinion from the United States Attorney General as to the full extent to which benefits were authorized under this decision. On March 16, 1995, amended regulations were published deleting the fault or accident provision of 38 C.F.R. § 3.358 in order to conform the regulation to the Supreme Court’s decision. The Board notes that during the pendency of the instant appeal the Departments of Veterans Affairs and Housing and Urban Development, and Independent Agencies Appropriations Act, 1997 (Act), Pub. L. No. 104-204, __ Stat. ___ (1996), was enacted. In pertinent part, this Act serves to amend 38 U.S.C. § 1151 with regard to what constitutes a “qualifying additional disability” susceptible of compensation. However, the Act specifies that the amendments to 38 U.S.C. § 1151 are effective for appeals filed after October 1, 1997. Hence, they are not applicable in this case. At a personal hearing before a member of the Board in February 1998, the veteran clarified that his representative for purposes of this claim was the Paralyzed Veterans of America. He also clarified that the issues related to his 38 U.S.C.A. § 1151 claims, and his intentions are reflected in the characterization of the issues as they are listed on the first page of this decision. Two additional issues for entitlement to benefits under 38 U.S.C.A. § 1151 for residuals of a urethral injury (i.e., an atonic or neurogenic bladder) as a result of treatment during hospitalization at a VA facility from September 8, 1992 to December 15, 1992 and for residuals of a tonic clonic seizure (i.e., a shoulder disability) as a result of a myelogram performed at a VA facility on October 1, 1992 were also noted at the hearing to be certified and developed for appellate review. However, because the benefits sought with those claims are being granted on an alternative basis in this decision, the issues are considered moot, and will not be addressed herein. Additionally, at the hearing, the veteran's service representative raised the issue of service connection for cervical spine disability as secondary to the veteran's service connected bilateral knee disorders. This issue has not been adjudicated by the RO and has not been certified for appeal. It is referred to the RO for any appropriate development. Finally, the veteran submitted additional evidence, including medical opinions, directly to the Board in support of his claims. The RO has not reviewed this evidence, and the veteran clearly indicated that a waiver of consideration by the RO would only be granted if the evidence could be used by the Board in his favor. See 38 C.F.R. § 20.1304(c). The Board further notes that in a December 1995 rating decision, the RO denied the veteran's claim for increased ratings for bilateral knee disorders, bilateral hip disorders and a back disorder, but granted entitlement to a total rating based on individual unemployability due to service connected disabilities. The issues related to the increased ratings have not been certified for appeal and are not presently before the Board. Therefore, they will not be addressed herein. The issue of entitlement to benefits under 38 U.S.C.A. § 1151 for additional disability of the cervical spine as a result of treatment and surgery at a VA facility in July and/or October 1992 will be addressed in the Remand that follows this decision. The issue of entitlement to special monthly compensation based on the need for aid and attendance will be held in abeyance and should be reconsidered by the RO in light of the determinations made in this decision as well as any determination regarding the issue that is remanded. CONTENTIONS OF APPELLANT ON APPEAL The veteran asserts that he has an atonic or neurogenic bladder as a result of surgery performed at a VA facility in July 1992. He also asserts that he has additional left shoulder disability as a result of treatment at a VA facility in October 1992. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1997), has reviewed and considered all of the evidence and material of record in the veteran's claims files. Based on a review of the relevant evidence, and for the following reasons and bases, it is the decision of the Board that the evidence supports the grant of benefits under 38 U.S.C.A. § 1151 for an atonic or neurogenic bladder as a result of surgery performed at a VA facility in July 1992. It is the further decision of the Board that the evidence supports the grant of benefits under 38 U.S.C.A. § 1151 for additional left shoulder disability as a result of treatment at a VA facility in October 1992. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained. 2. During VA hospitalization in July 1992, the veteran underwent a laminectomy and posterior spinal fusion which resulted in an atonic bladder. 3. During VA hospitalization in October 1992, the veteran had a tonic clonic seizure as a result of an allergic reaction to the dye used for a myelogram, and he was dropped by an ambulance crew when he was transported for tests. 4. The medical evidence establishes that the veteran’s left shoulder impairment was aggravated by these incidents. CONCLUSIONS OF LAW 1. Benefits under 38 U.S.C.A. § 1151 for an atonic or neurogenic bladder as a result of surgery performed at a VA facility in July 1992 are warranted. 38 U.S.C.A. §§ 1151, 5107 (West 1991 & Supp. 1997); 38 C.F.R. § 3.358 (1997). 2. Benefits under 38 U.S.C.A. § 1151 for additional left shoulder disability as a result of treatment at a VA facility in October 1992 are warranted. 38 U.S.C.A. §§ 1151, 5107 (West 1991 & Supp. 1997); 38 C.F.R. § 3.358 (1997). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, we note that we have found that the veteran’s claims are well grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented claims which are plausible. See Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). The Board is also satisfied that all relevant facts have been properly developed and that no further assistance is required in order to comply with the duty to assist mandated by 38 U.S.C.A. § 5107. Littke v. Derwinski, 1 Vet.App. 90 (1990). I. Factual Background Service medical records demonstrate that the veteran injured his knees when he fell out of a helicopter. He is currently service connected for bilateral knee disorders, bilateral hip disorders, and a back disorder. In a February 1988 decision, the Board denied service connection for a cervical spine disorder as secondary to his service connected disabilities concluding that the disorder resulted from injuries the veteran sustained in a motor vehicle accident which occurred after service. A June 1991 letter from a VA physician reported that the veteran had significant weakness of the left upper and lower extremity due to cervical myelopathy which was caused by cervical stenosis. Surgical intervention was recommended. A discharge summary from the New Orleans, Louisiana VAMC reported that the veteran was hospitalized from June 12, 1991 to August 12, 1991. The veteran indicated that he had an eight month history of increased difficulty in walking which he believed to be secondary to his bilateral knee disorders. However, he then realized that it was for a different reason. He gave a history of a previous C5 through C7 anterior cervical fusion. A myelogram and CT showed C3-4 and C4-5 anterior defects due to spondylosis and possible disc disease. He was admitted and underwent C3-4 and C4-5 anterior cervical fusion on June 27, 1991. The discharge diagnosis was C3-4, C4-5 myelopathy secondary to spinal stenosis. A discharge summary from the Washington, D.C. VAMC reported that the veteran was hospitalized from July 6-10, 1992 for cervical disc disease. He complained of pain and paresthesias of the left upper and lower extremities, which was greater on the left than the right. It was noted that surgery had been performed in 1991; however, two months later he noticed gradual weakness in the left arm and leg. An April 1992 MRI showed impingement and stenosis of C3, C4, and C5. An EMG done in January 1992 revealed decreased nerve velocity. He indicated that he could not lift more than 10 pounds with his left arm. He also had repeatedly fallen due to weakness. Examination of the neck revealed a greatly decreased range of motion and anterior surgical scars. Motor examination indicated triceps strength of 5+ on the right and 4 on the left; biceps strength of 5 on the right and 4 on the left; grip strength of 5 on the right and 3 on the left. The iliopsoas was 4+, bilaterally; the leg flexors were 3+ on the right and 4+ on the left. The calves showed 5/5 for both dorsiflexion and plantar flexion. The sensory examination was within normal limits to light touch and proprioceptions. He was admitted with the stipulation that he would be transferred to the Richmond VAMC for surgery. A discharge summary from the Richmond, Virginia VAMC reported that the veteran was admitted to neurosurgery on July 13, 1992 and was transferred to rehabilitation on August 5, 1992. He was discharged on September 3, 1992. He had been diagnosed with cervical myelopathy and surgery was recommended. On July 22, 1992, a decompressive laminectomy of C3-6 and partial C2 laminectomy with posterior spinal fusion of C2-7 was performed. Afterwards, the veteran had difficulty voiding his bladder, and urodynamic studies showed an atonic bladder. Six hour intermittent catheterization was recommended. It was noted that the veteran made rapid progress in regaining strength during rehabilitation and was able to ambulate independently without assistive device. An operation report from the Richmond, Virginia VAMC indicated that the veteran underwent a cervical laminectomy on July 22, 1992. It was noted that the incision needed to be lengthened and eventually the spinous process was floating free. Afterwards, there was good decompression of the cord and the procedure was completed. A discharge summary from the Washington, D.C. VAMC reported that the veteran was hospitalized from September 8, 1992 to December 15, 1992. It was noted that his hospital course had been complicated by a grand mal tonic clonic seizure which occurred when a myelogram was performed on October 1, 1992. The seizure was believed to be caused by the myelogram dye. An incident report filed by a VA physician confirmed the reaction. An October 1992 consultation record noted that the veteran had a seizure during a myelogram and he now complained of increased weakness in his left arm and leg. An October 20, 1992 progress note reported that the veteran complained of a stiff and painful neck secondary to his stretcher being dropped by the ambulance crew the previous night during a trip to Wheaton, Maryland for an MRI. A November 4, 1992 progress note indicated that an orthopedist was to see the veteran regarding a rotator cuff tear which was secondary to the seizure. A correction to the discharge summary from September 8, 1992 to December 15, 1992 was requested by the veteran and was completed in February 1994. It noted that the veteran had spasms in his left shoulder and scapula during the seizure that occurred on October 1, 1992. The physician was unable to provide an opinion regarding the permanency of residuals from this injury. He was also unable to provide an opinion regarding the incident with the stretcher and its relationship to the veteran's medical problems. A discharge summary from the Washington, D.C. VAMC reported that the veteran was hospitalized from May 7, 1994 to June 2, 1994. He had presented to the emergency room with progressive worsening of gait, increased weakness and stiffness of the lower extremities, and mild weakness in the left upper extremity. He denied any change in bowel or bladder function. It was noted that he had a history of cervical injury secondary to a motor vehicle accident and had multiple cervical surgeries since 1972. An MRI of the lumbosacral spine revealed degenerative disc disease of L3 through S1 and diffuse disc bulge at L5 through S1 with some left neural foramen narrowing at this level. An MRI of the cervical spine revealed status post C5 through C6 fusion, severe spondylosis of the entire cervical spine, spinal cord atrophy and spinal canal stenosis at C3 through C5. Physical therapy during the hospitalization alleviated the neck and back pain significantly. He was discharged with more intense physical therapy scheduled. After he completed physical therapy, the veteran was again hospitalized at the Washington, D.C. VAMC from July 19, 1994 through August 11, 1994. He reported that he had gotten stronger, but that his bladder had shut down. As a result, he self catheterized every four hours. He was seen in the Urology department for an atonic bladder and he was seen by Orthopedics for a left rotator cuff injury. An MRI of the left shoulder showed that the left rotator cuff was intact without any tears appreciated by physical examination or imaging. A pelvic scan was normal. The discharge diagnosis was spastic quadriparesis secondary to cervical stenosis with atrophy. Secondary diagnoses were chronic degeneration in the left C4 through C6, maximal at C5, and an atonic bladder. In a February 1995 letter, C. James Duke, M.D., from Holy Cross Hospital, reported that the veteran underwent a myelogram at the Washington D.C. VAMC on October 1, 1992. During the procedure, he suffered an allergic reaction to the dye and had a seizure. When he regained consciousness, the veteran indicated that he felt an excruciating pain in the region of his left shoulder. Afterwards, he had trouble moving his left arm. Subsequently, the stretcher upon which the veteran was being transported was dropped on October 19, 1992. The veteran reported that it hit the ground rather hard and his head snapped backward and forward. He experienced an increased sense of numbness in all his limbs, plus increased pain in his left shoulder, neck and back. Dr. Duke opined that it seemed probable that the fall aggravated the veteran's cervical myelopathy, and that the shoulder pain was referred from the neck. The veteran underwent extensive physical therapy. Dr. Duke also noted that later evaluations indicated that the weakness of the veteran's left shoulder was related to his neck problems, but noted that the extreme weakness was aggravated by the incident on October 19, 1992. Finally, he noted that the veteran had an atonic/neurogenic bladder which preceded the surgery that was performed in July 1992. Nonetheless, he believed that it had become more severe since that procedure. A discharge summary from the Richmond VAMC reported that the veteran was hospitalized from February 21, 1995 to March 15, 1995. It was noted that he was status post motor vehicle accident in 1972 and had a long history of cervical spine disease. The had multiple surgeries including C5-C7 fusion in 1972 and C3-C5 fusion in 1991. In 1992, he had increased left upper extremity pain and weakness. Presently, he complained of worsening left shoulder pain and weakness. An MRI performed in August 1994 showed no rotator cuff tear, but was positive for deltoid atrophy and mild acromion impingement of the supraspinatus tendon. A urodynamic study completed in March 1995 revealed an areflexic detrusor muscle. The veteran participated in extensive physical and occupational therapy, with a primary focus on the left shoulder. The discharge diagnoses were: left shoulder subluxation, cervical spine disease, left C5-C6 radiculopathy, and bladder detrusor areflexia. On VA examination in June 1995, the veteran reported that he was involved in a motor vehicle accident in 1988 and sustained a spinal cord injury. In 1991, he had a C3, C4 and C5 anterior cervical fusion performed; and in 1992, a cervical C2, C3, C4, C5 and C6 laminectomy was performed. He was then hospitalized for eight months in 1992 for rehabilitation and again in 1994 for about five months. Presently, he complained of severe loss of motion in the neck, severe left arm weakness, and a loss of fine motor skills. He also had chronic constipation, a neurogenic bladder which required self-catheterization, and an unsteady gait. The diagnoses were: history of cervical fusion and laminectomy; severe mechanical low back pain; osteoarthritis of the hips, right greater than left; and severe osteoarthritis of the left knee. At a personal hearing in November 1996, the veteran testified that he had a seizure due to the dye that was administered during a myelogram in October 1992. He also noted that he sustained a urethral injury due to insertion of the wrong size Foley catheter which caused extensive bleeding, and that he has had a neurogenic bladder since the July 1992 surgery. He further reported that he was dropped by the ambulance attendants in October 1992 while he was being transported for an MRI. The fall exacerbated his left shoulder problem, and the shoulder was now permanently impaired. Finally, he related that prior to his treatment at the VA he had no problems with manual dexterity or sensation in his fingertips. Now he was unable to live independently because he could not perform many self-care functions, and could not tolerate hot and cold. A treatment summary report from the San Juan, Puerto Rico VAMC indicated that the veteran was hospitalized in January 1997. Initially, he was admitted to the neurosurgery ward and was then transferred to the spinal cord injury service. It was noted that his condition improved considerably and he was started on intermittent catheterization every six hours. However, this aspect of his rehabilitation had not improved and the schedule remained the same. A discharge summary from the Richmond, Virginia VAMC shows that the veteran was admitted on March 26, 1997 for evaluation by several services, including Rehabilitation Medicine, Physical Therapy, Occupational Therapy and Kinesitherapy. X-rays revealed degenerative joint disease of the acromioclavicular joint and glenohumeral joint and he was referred to a shoulder specialist. An MRI showed a full thickness tear of the rotator cuff muscle, atrophy of the rotator cuff muscle, as well as an injury to the glenohumeral labrum. Evaluation of the shoulder indicated that the veteran had reflex sympathetic dystrophy. In an April 1997 letter, Dr. Duke noted that the veteran had a seizure following a myelogram and thereafter noticed increased pain and limitation of motion in his left shoulder. The shoulder problems had nearly resolved when he was dropped while being transported to another facility. Dr. Duke opined that this event resulted in a significant aggravation in the veteran's cervical myelopathy. He indicated that it caused an accelerated decline in neurologic function, consisting of prominent sensory loss of the hands and increased muscle weakness, particularly in the left shoulder. Additionally, the left arm and hand had become diffusely more weak. On VA examination in September 1997, it was reported that the veteran had been hospitalized since January 1997 following a fall in his home which left him a C4-C5 incomplete quad. His gait was unsteady and his primary mode of mobility was a motorized wheelchair. He indicated that he needed assistance with all of his activities of daily living. He complained of pain in his neck as well as all his extremities. He noted that he was unable to utilize his left shoulder and often experienced a subluxation or dislocating sensation in the shoulder. Examination of the left shoulder revealed that forward flexion and abduction were only to 10 degrees, and there was no internal or external rotation. Passive range of motion was better, but resulted in anterior subluxation and almost dislocation of the shoulder. The veteran was unable to perform a shoulder shrug on the left side and he could not abduct, flex, or extend his left shoulder against resistance. The examiner reported that there was a great deal of atrophy of the left shoulder due to neurological damage. In a January 1998 letter, Craig N. Bash, M.D., a neuroradiologist and Deputy Director of Medical Services for Paralyzed Veterans of America, reported that he reviewed the veteran's extensive files and presented his opinion regarding the factors which caused the veteran's present neurologic condition. Dr. Bash noted that the veteran was involved in motor vehicle accidents in 1972 and 1988, and sustained cervical spine injuries which resulted in fusions of the cervical vertebrae C3 to C5, and from C5 through C7. In June 1991, the veteran underwent an anterior cervical fusion of C3-4/C4-5 at the VAMC in New Orleans, Louisiana when he began to experience symptoms of progressive lower extremity instability. The discharge diagnosis was C3-4,C4-5 myelopathy secondary to spinal stenosis. An April 1992 MRI of the cervical spine showed prominent, predominantly left sided spinal stenosis at C3-4 and C4-5 with associated impingement upon the spinal cord. On July 22, 1992, laminectomies of C2 through C6 were performed at the VAMC in Richmond, Virginia to achieve decompression of the spinal cord. Post-operatively, the veteran experienced bladder incontinence and urodynamic studies showed an atonic bladder. He was transferred for rehabilitation service, but at discharge in September, he was noted to have detrusor areflexia and required catheterization three times a day to void his bladder. Shortly thereafter, the veteran presented to neurological services with complaints of increasing weakness. An EMG showed maximal denervation at the C6 level. On October 19, 1992, the veteran was taken by ambulance to a center for an MRI. The ambulance crew dropped the stretcher upon which the veteran was being transported. An MRI completed on that day showed a small C5-6 herniation which was central and left paramedian. It was reported that this caused slight impingement of the anterior subarachnoid space, however, cord compression was not identified. Nonetheless, the veteran continued to report progressive weakness and stiffness in his lower extremities. In May 1994, the veteran was admitted with a four to five week history of progressive weakness and stiffness in his lower extremities and mild left upper extremity weakness. He had more intensive therapy at the Fort Howard VAMC in July 1994. On return to the Washington, D.C. VAMC, the bladder had “shut down” and the veteran could not ambulate long distances without his wheelchair. A CT scan ruled out localized pathology to account for urinary incontinence. He was discharged on straight catheterization. Dr. Bash’s impression was that the veteran had severe neurologic dysfunction secondary to cord compression. He further opined that the veteran had chronic sensory and motor strength impairment of the left upper extremity after the July 1992 surgery and the October 1992 accident. The veteran also had an atonic bladder since the July 1992 surgery which required catheterization for the past seven years. He concluded that the July 1992 surgery, and the accident in October 1992 caused a precipitous loss of neurologic function well beyond the expected natural progression of the degenerative changes that resulted from the veteran's original injuries to his cervical spine. At a personal hearing before a member of the Board in February 1998, the veteran testified that a cervical myelogram was performed on October 1, 1992 and all he remembered was waking up in the ICU all tied up. The physician informed him that he had a tonic clonic seizure. The veteran complained to him that he had a severe pain in his left shoulder. The veteran also testified that prior to the surgery in July 1992, he was able to walk on his own. After the surgery, he had an ataxic gait which was hesitant. Presently, he used a motorized wheelchair. He noted that he had a significant decrease in his fine motor skills after the tonic clonic seizure as well as the incident when his stretcher was dropped. He related that he had not been able to void his bladder spontaneously since the July 1992 surgery. II. Analysis In pertinent part, 38 U.S.C.A. § 1151 provides that, where any veteran shall have suffered an injury, or an aggravation of an injury, as a result of hospitalization, medical or surgical treatment, not the result of such veteran’s own willful misconduct, and such injury or aggravation results in additional disability to or the death of the veteran, disability or dependency and indemnity compensation benefits shall be awarded in the same manner as if such disability were service connected. The corresponding regulation provides: Compensation will not be payable under 38 U.S.C. § 1151 for the continuance or natural progress of disease or injuries for which the training, or hospitalization, etc., was authorized. Furthermore, in determining whether additional disability or death resulted from a disease or an injury or an aggravation of an existing disease or injury suffered as a result of training, hospitalization, medical or surgical treatment, or examination, the following considerations will govern: (1) It will be necessary to show that the additional disability is actually the result of such disease or injury or an aggravation of an existing disease or injury and not merely coincidental therewith; (2) The mere fact that aggravation occurred will not suffice to make the additional disability compensable in the absence of proof that it resulted from disease or injury suffered as the result of training, hospitalization, medical or surgical treatment, or examination; and (3) Compensation is not payable for the necessary consequences of medical or surgical treatment or examination properly administered with the express or implied consent of the veteran, or, in appropriate cases, the veteran’s representative. “Necessary consequences” are those which are certain to result from, or were intended to result from, the examination or medical or surgical treatment administered. 38 C.F.R. § 3.358(b)(2), (c)(1)(2)(3). The record reflects that the veteran sustained severe spinal injuries after he was involved in two motor vehicle accidents in 1972 and 1988. In 1992, he presented to the VA with increased symptomatology, including increased weakness and difficulty walking. He underwent a cervical laminectomy and posterior spinal fusion at a VA facility in July 1992. He related that, after the procedure, he was unable to void his bladder spontaneously and he has had an atonic bladder since that time. A VA discharge summary from the veteran's hospitalization from February 21, 1995 to March 15, 1995 noted a diagnosis of bladder detrusor areflexia. It is unclear whether the veteran ever regained use of his bladder intermittently, or whether the condition actually preceded the July 1992 surgery. Testimony and evidence related to this fact is in conflict. In fact, in a February 1995 letter, Dr. Duke noted that the veteran's atonic/neurogenic bladder preceded the surgery that was performed in July 1992. Additionally, in a January 1998 letter, Dr. Bash reported that the veteran had an atonic bladder that required catheterization for the past seven years, a timeline which establishes that the condition began sometime in 1991. However, Dr. Duke opined that the condition had become more severe since the July 1992 procedure. Based on this opinion, the Board may conclude that the veteran has additional disability, i.e., at least a more severe atonic or neurogenic bladder, as a result of the surgery that was performed at a VA facility in July 1992. Consequently, benefits pursuant to 38 U.S.C.A. § 1151 for such disability are warranted. The record also reflects that the veteran suffered a tonic clonic seizure as a result of an allergic reaction to the dye that was administered during a myelogram at a VA facility on October 1, 1992, and he complained of significant left shoulder pain after the incident. Additionally, the evidence shows that he was dropped by an ambulance crew on October 19, 1992 when he was transported to another facility for testing. Again, the veteran reported significant pain and impairment of the left shoulder after this incident. A VA discharge summary from the veteran's period of hospitalization from February 21, 1995 to March 15, 1995 noted a diagnosis of left shoulder subluxation. Another VA discharge summary from March 1997 reported that an MRI revealed a full thickness tear of the rotator cuff muscle, atrophy of the rotator cuff muscle, and an injury to the glenohumeral labrum. The evaluation concluded that the veteran had reflex sympathetic dystrophy of the left shoulder. In his February 1995 letter, Dr. Duke reported that the veteran's left shoulder disability was related to his cervical disability, but indicated that the extreme weakness was aggravated by the October 19, 1992 incident; and in his January 1998 letter, Dr. Bash determined that the veteran had chronic sensory and motor strength impairment of the left upper extremity after the October 19, 1992 accident. Based on these opinions, the Board may conclude that the veteran has additional left shoulder disability as a result of treatment at a VA facility in October 1992. Consequently, benefits pursuant to 38 U.S.C.A. § 1151 for this disability are also warranted. ORDER Benefits under 38 U.S.C.A. § 1151 for an atonic or neurogenic bladder as a result of surgery performed at a VA facility in July 1992 are granted. Benefits under 38 U.S.C.A. § 1151 for additional left shoulder disability as a result of treatment at a VA facility in October 1992 are granted. REMAND At a personal hearing before a member of the Board in February 1998, the veteran's service representative indicated that the veteran was claiming entitlement to benefits under 38 U.S.C.A. § 1151 for additional disability of the cervical spine as a result of surgery and/or treatment at a Department of Veterans Affairs facility in July and October 1992. The treatment in question specifically involved being dropped by the ambulance crew while being transported to a facility for an MRI. The surgery in question involved the procedure that was performed on July 22, 1992 at the Richmond, Virginia VAMC. Since the veteran only partially waived initial consideration of the medical evidence submitted at the hearing, referral of this evidence to the RO for initial consideration is mandated by 38 C.F.R. § 20.1304. Also, it appears from the record that the RO only considered the issue from the standpoint of additional disability as a result of being dropped by the ambulance crew. The question as to whether any additional cervical disability was caused by the surgery was not addressed by the RO. While a veteran may waive RO consideration of additional evidence presented to the Board, consideration of additional issues (or in this case an additional aspect of the same issue) must be returned to the RO for an initial determination. In light of the foregoing, and in order to fairly and fully adjudicate the veteran’s claim, the case is REMANDED to the RO for the following: 1. The RO should obtain copies of all recent treatment records related to the veteran's cervical spine disability, and associate them with the claims folder. 2. The RO should arrange for any development that is necessary to make a determination on this matter, including scheduling the veteran for any examinations and/or obtaining an expert opinion. If such an opinion is sought, the examiner should review the file in its entirety and render an opinion for the record as to whether the veteran has any additional disability of the cervical spine as a result of the July 1992 surgery and/or the October 1992 incident when he was dropped by the ambulance crew, or whether any additional disability is merely a natural progression of the veteran's condition or a necessary consequence of the procedures he has undergone for his disability. Any special tests or studies deemed necessary by the examiner should be accomplished. The rationale for the opinions expressed should be fully explained with references to the current evidence of record. The RO is reminded that only an opinion from a medical expert may be utilized in making a determination on this issue, and its judgment alone regarding the causal relationship between the veteran's present condition and the VA treatment in question, is not acceptable. 3. Following the completion of the foregoing, the RO must review the claims folder, and ensure that the requested actions are completed in full. Then, the RO should adjudicate the claim for entitlement to benefits under 38 U.S.C.A. § 1151 for additional disability of the cervical spine as a result of surgery and/or treatment at a VA facility in July and October 1992, and readjudicate the issue of entitlement to special monthly compensation benefits based on the need for regular aid and attendance. In the event the determinations remain adverse to the veteran, he and his representative should be provided an appropriate supplemental statement of the case and given the opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration. The veteran need take no action until he is notified. The Board intimates no opinion, either factual or legal, as to the ultimate conclusion warranted. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Veterans Appeals for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans’ Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1997) (Historical and Statutory Notes). In addition, VBA’s ADJUDICATION PROCEDURE MANUAL, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. GEORGE R. SENYK Member, Board of Veterans' Appeals NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1997), a decision of the Board of Veterans’ Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans’ Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date that appears on the face of this decision constitutes the date of mailing and the copy of this decision that you have received is your notice of the action taken on your appeal by the Board of Veterans’ Appeals. Appellate rights do not attach to those issues addressed in the remand, because a remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1997). - 2 -