CERVICAL SPINE LIMITATION OF MOTION

Summary

The veteran, who served in the U.S. Air Force from September 1988 to September 1992, including service in Saudi Arabia during the Persian Gulf War, appeals the denial of service connection for a neck/cervical spine disability. The veteran asserted that his neck condition was due to in-service aircrew duties as a loadmaster, involving strenuous physical activity, and claimed continuity of pain since service. He also advanced theories of military environmental exposures and secondary aggravation from his service-connected lumbar spine disability. The Board reviewed multiple VA examinations and the veteran's lay statements. Early VA examinations were deemed inadequate for failing to address continuity of symptoms or the veteran's specific lay statements about his duties. Later VA examinations concluded the degenerative disc disease and arthritis in the cervical spine were less likely than not related to service, citing a lack of in-service complaints, a 2010 onset of symptoms post-service, and the known etiological factors of age and severe morbid obesity. The Board found these later opinions persuasive, noting the veteran's lay opinions on etiology were not competent medical evidence. The Board also found the claim for secondary service connection inadequate, as the degenerative changes were attributed to age and obesity, not the service-connected lumbar strain. The Board concluded that the weight of the evidence was against the veteran's claim, denying service connection for the neck/cervical spine disability.

Rationale

No in-service complaints or treatment for neck issues.; Post-service records show onset of neck pain in 2010.; Degenerative disc disease attributed to age and obesity.; In-service activities not of frequency/duration to cause DDD.; No nexus found for direct or secondary service connection.

Full Decision Text

Citation Nr: 24026242
Decision Date: 07/15/24	Archive Date: 07/15/24

DOCKET NO. 18-42 124
DATE: July 15, 2024

ORDER

Service connection for a neck/cervical spine disability is denied.

FINDING OF FACT

A neck/cervical spine disability is not shown to be causally or etiologically related to any disease, injury, or incident during service, arthritis did not manifest to a compensable degree within one year of separation from active duty, such disorder is not caused or aggravated by a service-connected disability, and such disorder is not a medically unexplained chronic multi-symptom illness (MUCMI).

CONCLUSION OF LAW

The criteria for service connection for a neck/cervical spine disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.317.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had active service in the United States Air Force from September 1988 to September 1992, including service in Saudi Arabia during the Persian Gulf War.

This matter comes to the Board of Veterans' Appeals (Board) on appeal for a rating decision issued in January 2017 by a Department of Veterans Affairs (VA) Regional Office. 

By way of background, the Board originally denied the Veteran's claim for service connection for a neck/cervical spine disability in July 2019, and the Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In July 2020, the Court issued a Joint Motion for Remand (JMR) vacating the decision and remanding the claim for action consistent with the terms of the JMR. After remanding the claim in January 2021 and December 2021 for additional development, the Board again denied the Veteran's claim for service connection in a January 2023 decision. The Veteran appealed the decision to the Court, which issued another Joint Motion for Partial Remand (JMPR) vacating the decision and remanding to the Board for readjudication. The Board remanded the claim in September 2023 for additional development and it now returns for further appellate review. 

It is of note that the Board also remanded a claim for entitlement to service connection for obstructive sleep apnea in September 2023. While on remand, in a March 2024 rating decision, the AOJ awarded service connection for obstructive sleep apnea. As such constitutes a full grant of benefits sought on appeal, the issue is no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997); A.B. v. Brown, 6 Vet. App. 35 (1993).

Entitlement to service connection for a neck/cervical spine disability.

Throughout the appeal period, the Veteran has asserted multiple theories as to the etiology of his neck/cervical spine disability. Specifically, he asserts that such is due to his in-service aircrew duties as a loadmaster on a C-141 in small compartments, in which he had to restrain odd-sized cargo, move around, and lift heavy objects, all of which strained his body and neck, and that he has experienced a continuity of neck pain since service. See November 2016 Statement in Support of Claim (VA Form 21-4138); February 2018 Notice of Disagreement. The Veteran also advanced the theory that his neck/cervical spine disability is due to military environmental exposures. See February 2018 VA Form 21-4138.  Finally, the Veteran claims that such is caused or aggravated by his service-connected lumbar spine disability. See July 2023 Appellate Brief.

Legal Requirements

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v
 Requirements

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996).

Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as arthritis, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

Service connection may also be granted for a disability due to a qualifying chronic disability of a veteran who served in the Southwest Asia Theater of Operations during the Persian Gulf War provided that such disability became manifest during either active service in the Southwest Asia Theater of Operations during the Persian Gulf War or to a degree of 10 percent or more, under the appropriate diagnostic code of 38 C.F.R. § Part 4, not later than December 31, 2021, and by history, physical examination, and laboratory tests, the disability cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1). In the instant case, the record reflects that the Veteran had active service in Saudi Arabia on August 21, 1990, and from March 7 to 8, 1991. Therefore, such laws and regulations are applicable to his claims.

A chronic qualifying disability means a chronic disability resulting from an (A) undiagnosed illness; (B) a medically unexplained chronic multisymptom illnesses (MUCMI) (such as chronic fatigue syndrome; fibromyalgia; irritable bowel syndrome; or any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a MUCMI); or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service connection. 38 C.F.R. § 3.317 (a)(2)(i).

For the purposes of this section the term MUCMI means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii).

"Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3).

Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. §
 unexplained. 38 C.F.R. § 3.317 (a)(2)(ii).

"Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3).

Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317 (a)(4).

Signs or symptoms which may be manifestations of undiagnosed illness or MUCMI include, but are not limited to: (1) fatigue, (2) unexplained rashes or other dermatological signs or symptoms, (3) headache, (4) muscle pain, (5) joint pain, (6) neurological signs and symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the upper or lower respiratory system, (9) sleep disturbances, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, (12) abnormal weight loss, and (13) menstrual disorders. 38 C.F.R. § § 3.317 (b).

Among the requirements for service connection for a disability due to an undiagnosed illness is that such disability, by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317 (a)(1)(ii). There must be no affirmative evidence that relates the undiagnosed illness to a cause other than being in the Southwest Asia Theater of operations during the Persian Gulf War. See 38 C.F.R. § 3.317 (c). If signs or symptoms have been attributed to a known clinical diagnosis in the particular veteran's case being considered, service connection may not be provided under the specific provisions pertaining to Persian Gulf Veterans. See VAOPGCPREC 8-98 at paras. 4-5 (Aug. 3, 1998).

In the case of claims based on an undiagnosed illness under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, unlike those for direct service connection, there is no requirement of a nexus or association between the claimed disability and in-service incurrence or aggravation. See Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004).

Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). 

Factual Background

The Veteran's service treatment records (STRs) are negative for any complaints, treatment, or diagnosis referable to neck or cervical spine pain. His spine was normal on medical examinations in October 1988 and December 1989. In dental patient medical histories dated February 1991 and December 1991, the Veteran reported that he was in good health, and specifically denied a history of arthritis. On periodic medical examination in December 1991, his neck and spine were clinically normal. Service personnel records reflect that the Veteran declined a separation medical examination in September 1992.

VA and private post-service medical records are negative for complaints, treatment, or diagnosis of a cervical spine disability until 2010, despite the fact that the Veteran sought treatment for several other medical conditions from 2000 to 2010.  Specifically, in May 2010, he reported neck pain which has been ongoing for the past three years without any particular injury. An X-ray at the time revealed degenerative disc disease (DDD) of the cervical spine and the Veteran was referred to physical therapy.

The Veteran was initially afforded a VA examination in January 2017, at which time cervical spine degenerative arthritis was noted. The examiner opined that the Veteran's cervical spine DDD was less likely than not incurred in
 1992.

VA and private post-service medical records are negative for complaints, treatment, or diagnosis of a cervical spine disability until 2010, despite the fact that the Veteran sought treatment for several other medical conditions from 2000 to 2010.  Specifically, in May 2010, he reported neck pain which has been ongoing for the past three years without any particular injury. An X-ray at the time revealed degenerative disc disease (DDD) of the cervical spine and the Veteran was referred to physical therapy.

The Veteran was initially afforded a VA examination in January 2017, at which time cervical spine degenerative arthritis was noted. The examiner opined that the Veteran's cervical spine DDD was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationale, it was noted that the STRs did not note any neck complaints or treatment during active service and VA treatment records reflect complaints of neck pain in 2010. Thus, as there was no evidence of injury in service or chronicity since service, the examiner was unable to establish a nexus. 

As noted in the July 2019 denial, the Board found the January 2017 VA examiner's opinion to be persuasive in finding the Veteran's cervical spine disability is not related to his active duty service. Moreover, the Board noted that the Veteran did not offer evidence to the contrary. However, in the July 2020 JMR, the parties determined that the January 2017 VA examiner failed to offer an adequate rationale, as he simply stated that the Veteran was not injured in service and his symptoms did not begin in service. 

Accordingly, the Veteran was provided an additional VA examination in February 2021. The VA examiner at the time opined that it is less likely than not that the Veteran's DDD of the cervical spine was incurred in or caused by the claimed in-service injury or illness. Here, the VA examiner noted that the Veteran's STRs did not mention neck problems and VA records show initial complaints of neck pain in 2010, which were of three years duration. Notably, the Veteran did not seek care for neck pain during service and his description of activities while on active service were not of a frequency or duration to lead to degenerative changes of the cervical spine almost 20 years later. 

However, in the December 2021 remand, the Board noted that the examiner did not address the Veteran's lay statements regarding continuity of pain since service; and thus, such opinion is inadequate. See McKinney v. McDonald, 28 Vet. App. 15, 30-31 (2016) ("the VA examiner's failure to consider [the Veteran's] testimony when formulating her opinion renders that opinion inadequate.").

Thus, in the January 2023 decision, the Board determined that, taken together, the February 2021 and March 2022 VA examiners' opinions establish that the Veteran's cervical spine disability is not at least as likely as not related to an in-service injury, event, or disease, including his in-service aircrew duties as a loadmaster restraining, lifting, and moving cargo. The February 2021 VA examiner opined that the Veteran's cervical spine disability was not at least as likely as not related to in-service activities requiring awkward positions and heavy lifting, pushing, and pulling, while the March 2022 VA examiner opined that the Veteran's cervical spine disability was not at least as likely as not related to events in service.

The combined rationale was that there was no mention in the Veteran's service treatment records of neck pain or problems, VA medical records showed complaints of neck pain in 2010 that were of three years' duration, and the in-service activities described by the Veteran were not of a frequency or duration to lead to degenerative changes of the cervical spine noted almost 20 years later. The March 2022 VA examiner noted that the Veteran separated from service in 1992, and cervical degenerative disc disease was diagnosed in 2010 with a reported onset of 2007, and there was no evidence of a neck condition in service or in post-service records until 2010. At the time, the Board found the examiners' combined opinions to be probative, because they were based on an accurate medical history and provided an explanation that contained clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (stating that "the Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion.").

However, following the issuance of the June 2023 JMPR, the Board determined that the March 2022 VA opinion is also inadequate as it failed to address the continuity of symptomatology and the
2010. At the time, the Board found the examiners' combined opinions to be probative, because they were based on an accurate medical history and provided an explanation that contained clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (stating that "the Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion.").

However, following the issuance of the June 2023 JMPR, the Board determined that the March 2022 VA opinion is also inadequate as it failed to address the continuity of symptomatology and the Veteran's lay statements regarding his aircrew duties performed during service. 

Thereafter, in December 2023, a VA examiner opined that the Veteran's neck disability is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale was that while the Veteran contends that his neck pain is due to what he claims as the intense physical activities in service, there are no records during his time in service that note his neck issues while in service. The examiner explained that the Veteran does have post military records noting neck issues; notably, in 2010 it was noted that he has had neck pain for 3 years, which would be after his time in service. The examiner opined that without corroborating evidence that the Veteran's neck issues were incurred during his time in service, it is hard to prove that his current neck issues are the same neck issues that the Veteran claims started while in service. Thus, the examiner concluded it is less likely than not that the Veteran's cervical strain, cervical degenerative disc disease, and degenerative arthritis were incurred during his time in service, to include as due to his aircrew duties. 

With respect to the Veteran's claim that his neck disability is secondary to his service-connected lumbar spine disability, the December 2023 VA examiner opined that such is less likely than not. The examiner's rationale noted that the Veteran stated that he started having neck pain during his time in service due the physical activities that affected his neck while in service. The examiner acknowledged that the Veteran is service connected for lumbsacral strain. However, the examiner confusingly indicated that, "neck conditions are typically associated with lumbar issues in that one injury does not necessitate the injury to the the [sic.]other area of the spine." The examiner concluded it is less likely than not that the Veteran's cervical strain, cervical DDD, and degenerative arthritis were caused by or underwent any incremental increase in disability due to his lumbosacral strain.

Here, the Board finds the December 2023 VA examiner's opinions to be inadequate. As an initial matter, the opinion again fails to address the continuity of symptomatology and the Veteran's lay statements regarding his aircrew duties performed during service. Additionally, the opinion regarding secondary service connection relies on the Veteran's reports that his neck pain began in service, which is seemingly contradictory to the examiner's conclusions that the cervical spine disability was not incurred in service.

Thereafter, in an April 2024 opinion, a different VA examiner stated that the medical record clearly contradicts that the Veteran's current neck pain and symptoms had onset in service. Specifically, the examiner noted that neck condition VA examination report and post military records indicate a clear onset of the current symptoms around 2007 and STRs are silent for neck pain. The examiner explained that the Veteran's lay statements are considered correct at face value unless clearly contraindicated in the medical record or if they cannot be considered medically accurate from an anatomical, physiologic, and/or pathologic medical knowledge. 

The examiner then explained that the Veteran's current neck diagnosis of DDD is based on a known etiology and pathology. The examiner opined it is therefore medically unlikely that this disease started or had onset in service as it is a condition of mostly of age and prolonged wear associated with age. The examiner noted the Veteran had a short duration of service and at a young age. In citing relevant medical literature, the examiner provided that degenerative disc disease develops from loss of hydration in the gelatinous substance in the disc between the vertebrae, leading to narrowing of the disk space and fragile disc walls making it easier for them to tear and/or bulge. The examiner explained that as the disc changes develops, the vertebrae grow bone spurs in an attempt to help stabilize the spine leading to further encroachment and compression on the nerve roots exiting between the vertebrae. DDD of the spine is a process of aging, wear, and tear. As discs degenerate, loss of hydration of the gel inside of the discs causes a decrease in size and flexibility of the outer layer which makes it more prone for
 In citing relevant medical literature, the examiner provided that degenerative disc disease develops from loss of hydration in the gelatinous substance in the disc between the vertebrae, leading to narrowing of the disk space and fragile disc walls making it easier for them to tear and/or bulge. The examiner explained that as the disc changes develops, the vertebrae grow bone spurs in an attempt to help stabilize the spine leading to further encroachment and compression on the nerve roots exiting between the vertebrae. DDD of the spine is a process of aging, wear, and tear. As discs degenerate, loss of hydration of the gel inside of the discs causes a decrease in size and flexibility of the outer layer which makes it more prone for tearing. As the disc shrinks in size, the space between the vertebrae becomes smaller, bone spurs develop to help protect the spine and leads to compression of the nerve roots as they exit between the vertebra which leads to inflammation and pain. This wear and tear accumulates over many years. The examiner further noted that DDD is not associated or causes by acute back injuries or strains of the muscles and ligaments. The examiner also indicated that DDD is not caused by other musculoskeletal injuries in other joints such as hip or knee and cannot spread from one spine to the other.  

Specific to the Veteran's case, the examiner noted that he has a diagnosis of severe obesity with a body mass index (BMI) of 42. The examiner explained that obesity, particularly the distribution of adiposity in the trunk of the body, is strongly linked to biomechanical changes that damage the spine and contribute to a range of spinal diseases including intervertebral disc degeneration, spinal stenosis, reduced disc height, herniation of the disc, hypertrophy of the spinal ligaments, osteoarthritis, and increased compression forces on disc surfaces. This includes the cervical spine.   Additionally, the examiner noted that Teraguchi et al. investigated the prevalence and distribution of intervertebral disc degeneration over the entire spine and found the age and obesity were associated with the presence of disc degeneration in all areas of the spine, indicating that obesity places stress across multiple regions of spine. 

Thus, the examiner opined that the medical record clearly indicates the onset of the Veteran's neck pathology to be in 2007 and not continuous since service. The examiner next noted that the Veteran's condition is spinal degeneration and arthritis and he has major risk factors for this outside of military duties and service, to include severe morbid obesity and advanced age at onset. The examiner concluded that the known epidemiological, etiological, and pathological factors of the DDD and arthritis of the cervical spine make it less likely than not to have its onset in service. 

Additionally, the April 2024 VA examiner addressed the Veteran's statements regarding his aircraft duties during service and noted that based on known biomechanics of lifting, there is not an anatomical or physiologic possibility that lifting and moving objects would cause a load impact on the cervical spine or cause degeneration of the spine. The weight of an object being carried on the arms places the mechanical load on the middle and lower spine, and therefore would not be considered physiologically possible to cause stress or degeneration of the cervical spine. Therefore, in combination of the Veteran's pathological factors and risk factors, the examiner opined it is less likely than not that his current neck condition was caused by his in-service duties with aircrew. 

Finally, with respect to the Veteran's claim as to secondary service connection, the April 2024 VA examiner also provided that it is less likely than not that his cervical disability is caused or aggravated by his lumbar spine disability. As rationale, it was noted that a strain develops in muscles or tendons with tearing or overstretching that usually resolves with resting and conservative treatment.  Lumbosacral strain or sprain is not found to be associated or known to cause or aggravate DDD and arthritis of the cervical spine. The examiner again cited to the causes and development of DDD as discussed above and noted that the Veteran's degenerative arthritis of the cervical spine is due to advancing age and severe morbid obesity. 

Analysis

The Board affords great probative weight to the April 2024 VA examiner's opinion as such considered all pertinent evidence of record, to include the Veteran's statements and his relevant medical history, and provided a compete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez, supra; Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Notably, there is no medical
 is due to advancing age and severe morbid obesity. 

Analysis

The Board affords great probative weight to the April 2024 VA examiner's opinion as such considered all pertinent evidence of record, to include the Veteran's statements and his relevant medical history, and provided a compete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez, supra; Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Notably, there is no medical opinion to the contrary.

Finally, as discussed in the January 2023 Board decision, the Veteran's arthritis and DDD are diagnosed conditions. Therefore, they cannot be considered an undiagnosed illness, but they are eligible for consideration as a MUCMI. In VA Gulf War (GW) examinations, VA examiners are asked to characterize a Veteran's claimed disabilities as belonging to one of four disability patterns: (1) undiagnosed illness, (2) a diagnosable but medically unexplained chronic multi-symptom illness (MUCMI) of unknown etiology, (3) a diagnosable MUCMI with a partially explained etiology/pathophysiology, or (4) a disease with a clear and specific etiology. The Board may rely on a medical examiner's evaluation of whether a condition qualifies as a MUCMI. Goodman v. Shulkin, 870 F.3d 1383, 1387 (Fed. Cir. 2017). In this case, VA GW examiners in March 2018 and February 2021 each responded to the above opinion request, and indicated that the Veteran's cervical spine arthritis and degenerative disc disease have a clear and specific etiology and diagnosis, and concluded that they did not fall into one of the other three disability patterns (undiagnosed illness, MUCMI with unknown etiology, or MUCMI with a partially explained etiology/pathophysiology). The Board finds these opinions probative because they were provided by medical professionals, they are based on an accurate medical history, and provide an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, supra. Accordingly, as both the etiology and the pathophysiology of the Veteran's degenerative arthritis and degenerative disc disease of the cervical spine are at least partially understood, these diagnosed conditions are not considered MUCMIs and presumptive service connection is not warranted under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317.

The Board also considered the Veteran's assertions as to the etiology of his cervical spine; however, as a lay person, he does not have the requisite training and experience necessary to address such a complex medical matter. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of such disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and, thus, may not be competently addressed by lay statements. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Accordingly, the Veteran's opinions as to the etiology of his neck disorder are not competent evidence and, consequently, are afforded no probative weight.

Furthermore, the evidence of record fails to demonstrate that arthritis of the cervical spine manifested to a compensable degree within one year of separation from the Veteran's active duty service in September 1992. In this regard, he opted out of an examination at the time of separation from service, and the first indication of arthritis of the neck and right shoulder was noted in May 2010. Additionally, as arthritis was not "noted" in service, presumptive service connection for such chronic disease cannot be established based on a continuity of symptomatology. See Savage v. Gober, 10 Vet. App. 488, 495 (1997).

Therefore, the Board finds that a neck disability is not shown to be causally or etiologically related to any disease, injury or incident during service, arthritis did not manifest to a compensable degree within one year of separation from active duty and is not a MUCMI. Thus, service connection for such disorder is not warranted.
 examination at the time of separation from service, and the first indication of arthritis of the neck and right shoulder was noted in May 2010. Additionally, as arthritis was not "noted" in service, presumptive service connection for such chronic disease cannot be established based on a continuity of symptomatology. See Savage v. Gober, 10 Vet. App. 488, 495 (1997).

Therefore, the Board finds that a neck disability is not shown to be causally or etiologically related to any disease, injury or incident during service, arthritis did not manifest to a compensable degree within one year of separation from active duty and is not a MUCMI. Thus, service connection for such disorder is not warranted. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the weight of the probative evidence is against the Veteran's claim for service connection for a neck disorder, that doctrine is not applicable in the instant appeal and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 

 

Wendy Daknis

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J. Waite

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.