Citation Nr: 9910544 Decision Date: 04/15/99 Archive Date: 04/29/99 DOCKET NO. 96-40 225 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston- Salem, North Carolina THE ISSUE Entitlement to service connection for multiple sclerosis. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. A. Markey, Associate Counsel INTRODUCTION The veteran served on active duty from January 1964 to January 1967. This matter came before the Board of Veterans' Appeals (Board) from an October 1995 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina that denied the veteran's claim for entitlement to service connection for multiple sclerosis. A notice of disagreement was received in May 1996. A statement of the case was issued in May 1996. A substantive appeal was received from the veteran in July 1996. A hearing was held at the RO in October 1996. In August 1997, the Board remanded this matter to the RO for further development, which, the Board finds was accomplished. See Stegall v. West, 11 Vet. App. 268 (1998). FINDING OF FACT The preponderance of the medical evidence does not establish that the veteran currently suffers from multiple sclerosis. CONCLUSION OF LAW Entitlement to service connection for multiple sclerosis is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board finds that the veteran has submitted evidence that is sufficient to justify a belief the his claim for service connection for multiple sclerosis is well grounded. 38 U.S.C.A. § 5107(a) (West 1991), Murphy v. Derwinski, 1 Vet.App. 78 (1990). With respect to this claim, all relevant evidence has been fully developed and, therefore, the VA's duty to assist the veteran has been satisfied. Id. Applicable law provides that service connection will be granted if it is shown a particular disease or injury resulting in disability was incurred or aggravated during active duty. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303 (1998). Multiple sclerosis will be presumed to have been incurred in service if it was manifested to a compensable degree of disability within seven years of the veteran's separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 1991 & Supp. 1998); 38 C.F.R. §§ 3.307, 3.309 (1998). A "determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet.App. 309, 314 (1993). The appellant contends that service connection is warranted for multiple sclerosis. The evidence of record demonstrates the following: the veteran was first seen in May 1986 by G. Frank Crowell, M.D. complaining of malaise and some blurred vision, among other things. Dr. Crowell suspected that the veteran had experienced a transient ischemic attack. A magnetic resonance imaging (MRI) study of the veteran's head was performed at that time, and upon his review of the study, Dr. Crowell concluded that it showed an area of increased signal in the white matter in the left prieto-occipital region which was adjacent to the left occipital horn, noting that this may represent an isolated area of demyelination. He added that without any definite secondary areas of inflammation, a diagnosis of multiple sclerosis could not be made but was within the differential at the time. The veteran was seen again by Dr. Crowell in July 1986 complaining of an episode that took place in June 1986 involving right arm numbness, paresthesias, and dragging of the right leg. The veteran also complained of blurred vision and morning headaches at the time. Dr. Crowell discussed with the veteran the possibility of a demyelinating disease such as multiple sclerosis, noting also that the possibility of a arteriogram was also discussed, given the recurrent episodes. In November 1986, the veteran was seen at Wake Forest University's Bowman Gray School of Medicine (Bowman) and a neurologic examination was conducted, after which a tentative diagnosis of multiple sclerosis was discussed. He returned to this facility in May 1987 reporting that he had experienced blurred vision, fatigue, and numbness of the left lower extremity, among other things, since December 1986. Follow-up neurological examinations conducted in June and July 1988 were essentially normal. A VA neurologic examination was accomplished in June 1990, the report of which notes the above documented history of treatment with Dr. Crowell, as well as the veteran's reports of occasional episodes of mild weakness and numbness, and some right side incoordination. On neurologic examination, the cranial nerves were intact, the optic disc somewhat pale bilaterally. Visual fields were full to confrontation; deep tendon reflexes were brisk and symmetrical throughout without pathologic response. Sensory examination was intact, as was cerebral examination. The veteran's gait, stance, equilibrium, speech, and mental status was appropriate. The examiner's assessment was that the examination was normal with a history of either a transient ischemic attack, demyelinating disease, or other problems such as mixed collagen and vascular disease with vasculitis possibly associated with demyelinating in the central nervous system. The veteran was again seen by Dr. Crowell in March 1993, who examined him, ordered future testing, and put him on a short course of Medrol to give him some symptomatic relief since multiple sclerosis "was still a very likely possibility although not definitive." Another MRI of the head ordered by Dr. Crowell was performed in April 1993. The reading examiner's impression was that the scan of the brain was abnormal consistent with multiple small lacunar infarctions, that changes noted were not classically those seen with demyelinating disease, and that a lesion in the left occipital pole was noted which could represent a residual of old head trauma. The veteran was again seen by Dr. Crowell in March 1994, and related that he had had been experiencing bilateral leg and right arm weakness, blurred vision, and fatigue. Dr. Crowell and the veteran discussed starting the veteran on Betaseron, and the fact that his multiple sclerosis was more chronic than exacerbating. In July 1995, Dr. Crowell reported that an examination conducted at that time revealed no neurologic abnormality. In August 1995, Dr. Crowell sent a letter to Douglas R. Jeffery, M.D. (from the Department of Neurology at Bowman) wherein he noted that he had been following the veteran for many years with a diagnosis of possible multiple sclerosis, and noted that the veteran appeared to have more of a chronic, progressive type of multiple sclerosis. Dr. Crowell asked Dr. Jeffery to see the veteran, noting that it was his understanding that Dr. Jeffery was conducting a study with chronic, progressive multiple sclerosis patients. Dr. Jeffery examined the veteran in November 1995. In a report to Dr. Crowell, Dr. Jeffery noted the veteran's questionable history of multiple sclerosis since 1986, and noted that at that time (i.e. May 1986) an evaluation was prompted by the onset of a transient ischemic attack which involved right side weakness and aphasia and lasted twenty minutes. He also noted that an MRI study at the time showed an area of increased signal in the white matter in the left prieto-occipital region which was adjacent to the left occipital horn, that it was felt at the time that this may have represented an isolated area of demyelination, and that the veteran subsequently underwent visual, auditory, and somatosensory evoked potentials, all of which were normal. On neurologic examination, Dr. Jeffery found the veteran to be alert and oriented, and noted that his language and cognition were intact. Examination of the veteran's eyes was essentially normal except for a mild gaze evoked nystagmus at the furthest excursions of eye movement. The rest of the cranial nerves were found to be normal, as was his gait. The veteran was able to walk on his heels and toes, although tandem gait was off. Sensory examination was normal. Dr. Jeffery's impression was that he could not diagnose the veteran with multiple sclerosis. He pointed out that the veteran had only one clear-cut neurologic event which was more consistent with a transient ischemic attack than a multiple sclerosis exacerbation. Additionally, he added that he reviewed the veteran's most recent MRI, and that while there were some white matter lesions, they were in an unusual distribution for multiple sclerosis and perhaps could be accounted for better by some other process such as small vessel disease or some early white matter changes of aging. During an October 1996 RO hearing, the veteran testified that he suffers from multiple sclerosis manifested by occasional blurred vision, memory problems, sleep disturbance, anxiety, and depression. He also noted that his right foot drags. The veteran also testified that he was first told that he had multiple sclerosis in the spring of 1986 by Dr. Crowell. In August 1997, the claims folder was reviewed by Craig N. Bash, M.D., a neuroradiologist. In a memorandum, Dr. Bash stated that the veteran's documented complaints of right arm weakness and pain dated in May 1966, as well as testimony given by the veteran regarding this 1966 incident led him to believe that these events were the earliest manifestations of the veteran's multiple sclerosis. He also noted that two episodes of progressive multiple sclerosis may have also occurred in 1971 and 1972 when the veteran was treated for suspected Rocky Mountain Fever and Tourette's syndrome. Finally, another VA neurologic examination was accomplished in October 1998, the report of which again notes the veteran's neurologic history, and documents his current complaints of dragging his right leg and right arm tingling. During the examination, the veteran related that he had not been given therapy for multiple sclerosis, that he had not suffered from incontinence, episodes of unconsciousness, or diplopia. The veteran did note that acuity had been an occasional problem. Physical examination revealed that the veteran was able to stand on his toes and heels and could squat easily; that his pupils, discs, rotations, and fields were normal; that movements of the face, tongue and palate were symmetric and active; that there were no bruits in the neck, over the orbits, or over the scalp; and that strength of the deltoids, triceps, biceps, clasped hands, quadriceps, anterior tibials, and hamstrings was good. The veteran was able to lift himself off of his chair with his arms while seated. Reflexes of the biceps, triceps, brachial radialis, knees and ankles were symmetric and active. Babinski signs were absent, as were abdominal reflexes. On alternate motion, there was a slight tremor bilaterally. Straight leg raising was normal. Sensation was normal in all extremities, and joint sense was normal in the lower extremities. As a result of this examination, the veteran was diagnosed with ataxia, especially with his eyes closed; mild incoordination of gait and speech; and a long history of paresthesias and atypical lesions on his magnetic resonance imaging. The examiner added that he would classify the veteran's disability as multiple sclerosis suspect, noting that his problems could also be caused by unknown environmental exposure. The preponderance of the evidence detailed above does not establish that the veteran suffers from multiple sclerosis. The Board notes that references were made to the veteran's "multiple sclerosis" by Dr. Crowell, as documented above (in the March 1994 record and the August 1995 letter to Dr. Jeffery). However, in reviewing all of Dr. Crowell records, it is clear that he did not diagnose the veteran with multiple sclerosis; rather, he variously "diagnosed" the veteran with possible multiple sclerosis, tentative multiple sclerosis, and noted that the veteran possibly but not definitively had multiple sclerosis. In fact, in the same letter to Dr. Jeffery which he mentioned that the veteran suffered from a chronic, progressive type of multiple sclerosis, he also noted that he had diagnosed the veteran with possible multiple sclerosis. In any event, the report of Dr. Jeffery's thorough November 1995 examination, in addition to the October 1998 VA examination report, demonstrate that, while some symptoms related to multiple sclerosis may be present, the veteran has not been diagnosed with multiple sclerosis. Dr. Bash's opinion, to the effect that the veteran's multiple sclerosis had it's onset in service or just subsequent to separation from service is accepted as true for the purposes of well grounding this claim. See King v. Brown, 5 Vet.App. 19,21 (1993). However, it is clear that his opinion was made assuming the veteran had a current diagnosis of multiple sclerosis, which he did not, as noted above. In other words, Dr. Bash related certain alleged episodes of right arm weakness and pain in service and just subsequent to service as early manifestations of the veteran's multiple sclerosis without actually diagnosing the veteran with multiple sclerosis - apparently, he thought the evidence demonstrated that the veteran suffered from multiple sclerosis. However, since the veteran has not been clearly diagnosed with multiple sclerosis, such an opinion is of little probative value at this point. The Board notes that any lay statements made by the veteran do not provide a sufficient basis to conclude that he does suffer from multiple sclerosis. Espiritu. Since the preponderance of the evidence does not establish that the veteran has multiple sclerosis, his claim for service connection for this disorder must be denied. ORDER The appeal is denied. E. M. KRENZER Member, Board of Veterans' Appeals