Citation Nr: 0005602 Decision Date: 03/01/00 Archive Date: 03/14/00 DOCKET NO. 98-11 685 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for bilateral carpal tunnel syndrome. 2. A determination of the propriety of the initial disability rating of 10 percent assigned to the veteran's service-connected migraine headaches. 3. A determination of the propriety of the initial disability rating of 10 percent assigned to the veteran's service-connected joint space narrowing at L5-S1. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Andrew E. Betourney, Associate Counsel INTRODUCTION The veteran served on active duty from June 1978 to April 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 1998 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which denied the veteran's claim for service connection for bilateral carpal tunnel syndrome, and granted service connection for both migraine headaches and joint space narrowing at L5-S1, with a 10 percent disability evaluation assigned to each disorder. The veteran filed a timely appeal to these determinations. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appeal has been obtained by the RO. 2. The veteran has not submitted competent evidence which indicates that his current bilateral carpal tunnel syndrome is related to a disease or injury incurred in service. 3. The veteran's migraine headaches are not prostrating in nature, and generally respond to medication, but do occur as frequently as twice per week and cause some interference with employment. 4. The veteran's joint space narrowing at L5-S1 is manifested by subjective complaints of low back pain, with some radiation down the right leg. CONCLUSIONS OF LAW 1. The veteran's claim for service connection for bilateral carpal tunnel syndrome is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The schedular criteria for a disability rating in excess of 10 percent for migraine headaches have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1- 4.3, 4.7, 4.124a, Diagnostic Code 8100 (1999). 3. The schedular criteria for a disability rating in excess of 10 percent for joint space narrowing at L5-S1 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 4.1-4.3, 4.7, 4.71a, Diagnostic Code 5293 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service connection claim In order to establish service connection for a claimed disability, the facts, as shown by the evidence, must demonstrate that a particular injury or disease resulting in a current disability was incurred in or aggravated coincident with service in the Armed Forces. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303(a) (1999). However, the first step in this analysis is to determine whether the veteran has presented a well-grounded claim for service connection. In this regard, the veteran bears the burden of submitting sufficient evidence to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C.A. § 5107(a); Robinette v. Brown, 8 Vet. App. 69, 73 (1995). Simply stated, a well-grounded claim must be plausible or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). Where the determinative issue involves medical etiology or a medical diagnosis, competent medical evidence that a claim is "plausible" or "possible" is required for the claim to be well grounded. See Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997); Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Grottveit, 5 Vet. App. 91 (1993). This burden may not be met merely by presenting lay testimony, because lay persons are not competent to offer medical opinions. See Epps, supra; Grottveit, supra; Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). Service connection generally requires: (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed inservice disease or injury and the present disease or injury. See Epps, supra; Caluza v. Brown, 7 Vet. App. 498 (1995); see also Heuer, supra and Grottveit, both supra; Savage v. Gober, 10 Vet. App. 488, 497 (1997). In addition, a well-grounded claim may be established under the provisions of 38 C.F.R. § 3.303(b) when the evidence, regardless of its date, shows that a veteran had a chronic condition in service or during an applicable presumption period and still has such a condition. Such evidence must be medical unless it relates to a condition as to which, under the case law of the United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (Court), lay observation is competent. If the chronicity provision is not applicable, a claim may still be well grounded on the basis of § 3.303(b) if the condition observed during service or any applicable presumption period still exists, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology. Savage, 10 Vet. App. at 498. In the absence of evidence of a well-grounded claim, there is no duty to assist the claimant in developing the facts pertinent to the claim, and the claim must fail. Gregory v. Brown, 8 Vet. App. 563, 568 (1996) (en banc); Slater v. Brown, 9 Vet. App. 240, 243 (1996); Grivois v. Brown, 6 Vet. App. 136, 140 (1994); Grottveit, supra. Evidence relevant to the veteran's claim for service connection includes his service medical records, which reveal two instances of treatment for wrist pain. In August 1979, the veteran presented with a complaint of having experienced pain in the right wrist off and on for the previous six months. He stated that it had progressively worsened in the past two weeks. He reported that he noticed this pain while doing push-ups and lifting objects. On examination, the wrists were symmetrical, and range of motion of the right wrist was within normal limits, with some tenderness on the outer ranges of flexion and extension of the wrist. There was no palpable crepitus, and no history of any recent trauma. The examiner diagnosed probable tendonitis and musculoskeletal strain. A few months later, in April 1980, the veteran presented with complaints of cramping in both forearms since that morning. On examination, both arms were normal, as were the veteran's reflexes. However, the examiner noted that on mental status examination, the veteran was disoriented and was looking into space, and had constricted pupils. The examiner diagnosed unknown etiology, possible foreign substance abuse. There are no further recorded complaints or diagnoses of, or treatment for, forearm problems in the remaining seven years of the veteran's military service, and his April 1987 discharge examination indicated that his upper extremities were "normal." The first post-service evidence of a diagnosis of carpal tunnel syndrome is found in a treatment record dated in February 1996 from James Whitman, M.D., a physician in private practice. At that time, the veteran complained of bilateral wrist and hand pain of several months' duration, without paresthesias. It was noted that the veteran worked as a pipe-fitter, and used vibrating equipment. Following an examination, the examiner diagnosed rule out carpal tunnel syndrome, questionable neuropathy as well, and ordered nerve conduction studies. Also relevant are VA outpatient treatment notes dated from July 1995 to December 1996. These records indicate that a VA diagnosis of rule out carpal tunnel syndrome was first rendered in March 1996. Several subsequent diagnoses of carpal tunnel syndrome were also rendered, and an electromyogram (EMG) in April 1996 confirmed the presence of bilateral moderate carpal tunnel syndrome. The Board notes that the EMG report indicated that the veteran complained of tingling in the fingers of his left and right hands, and that these "symptoms began approximately two years ago." The examiner noted that the veteran worked as a pipe fitter and did a lot of heavy work with his hands such as hammering. These records also indicate that in May 1996 the veteran underwent a left carpal tunnel release. Although a cause of the veteran's carpal tunnel syndrome was not provided in this report, the examiner again noted that the veteran was a pipe fitter. In December 1997, the veteran underwent a VA neurological disorders examination. At that time, he reported that he suffered from hand numbness which started in the 1980's. He reported that it originally began in his right hand, but eventually affected his left hand as well. He noted that he had undergone a release procedure in his left hand, but complained that he still suffered from numbness in the first three fingers of both the right and left hands when using his wrist or hand. Following a physical examination, the examiner diagnosed carpal tunnel syndrome of the left and right hands, and status post carpal tunnel release on the left. A review of these records reveals that the veteran unquestionably suffers from bilateral carpal tunnel syndrome, and indeed has undergone a surgical procedure on the left for alleviation of this problem. However, the Board has found no medical evidence which links this current problem, first shown by the record to have been diagnosed in 1996, to the veteran's period of service which ended almost a decade earlier. Although the examiner who performed the December 1997 VA examination did note the veteran's report that he had suffered from wrist and hand numbness since the 1980's, this notation appears to merely reflect a recordation of historical information relayed by the veteran, rather than being based on a review of the veteran's medical record. Although, as noted above, the veteran did complain twice of wrist pain in 1979 and 1980, the only relevant diagnosis was the 1979 diagnosis of probable tendonitis and musculoskeletal strain. Neither examination report indicated a diagnosis of carpal tunnel syndrome. Furthermore, the veteran's service medical records are negative for any complaints or diagnoses of, or treatment for, wrist and hand pain or numbness for the remaining seven years of the veteran's period of active duty service, from 1980 to 1987 (or, indeed, any such complaints for many years after service, until 1996). In any case, "[e]vidence which is simply information recorded by a medical examiner, unenhanced by any additional medical comment by that examiner, does not constitute 'competent medical evidence...'" LeShore v. Brown, 8 Vet. App. 406, 409 (1995); see also Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Elkins v. Brown, 5 Vet. App. 474, 478 (1993). Furthermore, the Board notes that to the extent examiners have discussed the cause of the veteran's carpal tunnel syndrome, they have mentioned only the veteran's job as a pipe fitter, and the related use of vibrating equipment and heavy use of the hands, such as hammering, as a possible cause. In any case, there is nothing in the claims file, other than the veteran's own contentions, which would tend to establish that his current bilateral carpal tunnel syndrome is related to his active military service. The Board does not doubt the sincerity of the veteran's belief in this claimed causal connection. However, as the veteran is not a medical expert, he is not qualified to express an opinion regarding any medical causation of his carpal tunnel syndrome. As it is the province of trained health care professionals to enter conclusions which require medical expertise, such as opinions as to diagnosis and causation, Jones v. Brown, 7 Vet. App. 134, 137 (1994), the veteran's lay opinions cannot be accepted as competent evidence to the extent that they purport to establish such medical causation. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-5 (1992). See also Heuer v. Brown, 7 Vet. App. 379, 384 (1995), citing Grottveit, in which the Court held that an appellant does not meet his or her burden of presenting evidence of a well-grounded claim where the determinative issue involves medical causation and the appellant presents only lay testimony by persons not competent to offer medical opinions. Thus, the Board finds that the veteran's contention that his current carpal tunnel syndrome is related to claimed wrist pain and numbness experienced while in the military cannot be accepted as competent evidence. Accordingly, it is the decision of the Board that the veteran has failed to meet his initial burden of submitting evidence of a well-grounded claim for entitlement to service connection for bilateral carpal tunnel syndrome, and the claim must be denied on that basis. As the duty to assist is not triggered here by the submission of a well-grounded claim, the Board finds that VA has no obligation to further develop the veteran's claim. See Epps, supra; Grivois v. Brown, 5 Vet. App. 136, 140 (1994). In reaching this determination, the Board recognizes that this issue is being disposed of in a manner that differs from that employed by the RO. The RO denied the veteran's claim on the merits, while the Board has concluded that the claim is not well grounded. The Board has therefore considered whether the veteran has been given adequate notice to respond, and if not, whether he has been prejudiced thereby. Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Since the Court has held that "when an RO does not specifically address the question whether a claim is well grounded but rather, as here, proceeds to adjudication on the merits, there is no prejudice to the veteran solely from the omission of the well-grounded-claim analysis," the Board finds no prejudice to the veteran in this case. Meyer v. Brown, 9 Vet. App. 425, 432 (1996). In addition, in reaching this determination the Board notes that it has not been made aware of any outstanding evidence which could serve to well ground his claim for service connection for bilateral carpal tunnel syndrome. Accordingly, there is no further duty on the part of VA to inform the veteran of the evidence necessary to complete his application for this benefit. 38 U.S.C.A. § 5103 (West 1991); McKnight v. Gober, 131 F.3d 1483, 1484-85 (Fed. Cir. 1997). II. Disability rating claims The veteran has claimed entitlement to increased ratings for his service-connected migraine headaches and joint space narrowing at L5-S1. These are original claims placed in appellate status by a notice of disagreement (NOD) taking exception to the initial rating award dated in March 1998. Accordingly, his claims must be deemed well grounded within the meaning of 38 U.S.C.A. § 5107(a), and VA has a duty to assist the veteran in the development of the facts pertinent to his claims. See Fenderson v. West, 12 Vet. App. 119, 127 (1999) (applying duty to assist under 38 U.S.C.A. § 5107(a) to initial rating claims); cf. Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (increased rating claims). Under these circumstances, VA must attempt to obtain all such medical evidence as is necessary to evaluate the severity of the veteran's disabilities from the effective date of service connection to the present. Fenderson, supra., citing Goss v. Brown, 9 Vet. App. 109, 114 (1996); Floyd v. Brown, 9 Vet. App. 88, 98 (1996); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). See also 38 C.F.R. § 4.2 (ratings to be assigned "in the light of the whole recorded history"). This obligation was satisfied by the various examinations and treatment reports described below, and the Board is satisfied that all relevant facts have been properly and sufficiently developed. Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (1999). A. Migraine headaches Evidence relevant to the severity of the veteran's migraine headaches includes VA outpatient treatment notes dated from July 1995 to June 1998. These records indicate multiple instances of complaints of, and treatment for, headaches, variously diagnosed as vascular headaches, muscle contraction headaches, migraine headaches, and tension headaches. The veteran stated that he experienced nausea, photophobia, and phonophobia during his headaches, but no vomiting or emesis. The frequency of these attacks was described as having occurred an average of twice per week for the previous two years in October 1996 (at that time, he also reported that he had been able to work despite the headaches until the October 1996 visit), and twice per week again on several occasions in June 1998, although he described the attacks as weekly on one occasion in June 1998. Treatment consisted of the use of various medications, including Cafergot. However, there is some indication that the veteran did not take these medications as prescribed, as evidenced by a statement in October 1996 that the veteran "[h]as had poor compliance with all medications, only takes them approximately once [per] week." Similarly, a treatment note in June 1998 indicated that the "[p]atient got somewhat upset when I raised the issue of compliance but DW [discussed with] patient that often meds should be taken for a prolonged period to prevent HA's and he seemed better with this." Regarding the impact of these headaches, the Board notes that at the time of treatment in October 1996, the examiner indicated that "[a]t present slight nausea, no vomiting, no photophobia, able to perform daily activities. States he usually 'deals with it.'" In addition, at the time of treatment in June 1998, the examiner noted that medications gave occasional relief, "but the headaches are sometimes severe enough affect his work/construction." On another occasion in June 1998, the veteran stated that his headaches lasted anywhere from twelve to twenty-four hours and "often" required leaving work. In this regard, the Board notes that the veteran's claims file contains a statement from the veteran's employer, dated in May 1998. In this letter, the head of the safety department at the veteran's employer stated the following: [The veteran] has, on numerous occasions, complained to this department about experiencing severe headaches. At some times these headaches are so severe that they cause nausea. When this happens he, upon his own initiative, has to leave work. This letter did not indicate the frequency of the occasions when the severity of the veteran's headaches caused him to leave work. In December 1997, the veteran underwent a VA neurological disorders examination. At that time, he reported that he experienced headaches two to three times per week. He stated that when the pain occurred he usually had to continue his activities of daily living because of financial reasons. The pain reportedly lasted anywhere from four hours to as long as ten days. The headaches were occasionally accompanied by some nausea, although usually with no photophobia or phonophobia. He reported that his headaches usually responded to powder over-the-counter medications. Following an examination, the examiner diagnosed mixed headaches, migraine and muscle contraction tension headaches. The veteran's service-connected migraine headaches have been evaluated as 10 percent disabling under the provisions of 38 C.F.R. § 8100 (1999), pursuant to which the severity of migraine headaches is evaluated. Under this code, a 10 percent rating is warranted when migraines are characterized by prostrating attacks averaging 1 in 2 months over the last several months. In order to warrant a 30 percent rating, migraines must be characterized by prostrating attacks occurring, on average, once per month over the last several months. Finally, a 50 percent rating is warranted for migraines characterized by very frequent, completely prostrating, and prolonged attacks, which are productive of severe economic inadaptability. A review of the evidence detailed above reveals no evidence that the veteran's migraines are prostrating in nature. Indeed, the veteran stated on two occasions, in October 1996 and December 1997, that although his headaches were painful, he was able to perform daily activities, including work, and simply "dealt with it." He also indicated in June 1998 that while the use of over-the-counter medications occasionally relieved his pain, his headaches were "sometimes" severe enough to affect his work, which implies that usually they were not serious enough to affect it. He also noted in December 1997 that his headaches usually responded to over-the-counter medications, and other examiners noted that when his prescription medications did not work, it was often because of the veteran's non- compliance with the instructions for their use. There is evidence that the veteran's headaches cause him to miss work on occasion, and indeed his employer submitted a statement to that effect, indicating that at "some times" the veteran's headaches had required him to leave work. However, there is no indication that this is more than an occasional occurrence, particularly in light of the veteran's statements that he generally stayed at work even when he had headaches. However, the Board observes that the veteran's headaches clearly have caused him to miss work on some occasions. In addition, the veteran has generally stated that his headaches occur approximately twice per week, although this estimate has changed at times. Furthermore, there is evidence that the veteran's headaches, while sometimes lasting as little as four hours, at times can last as long as ten days. Therefore, the Board finds that, despite the lack of evidence of "prostrating" attacks, the veteran's headaches more closely approximate the level of severity contemplated by a 10 percent rating under DC 8100. However, as the evidence does not show that the veteran has experienced prostrating attacks on a monthly basis in the past several months, a higher, 30 percent rating is not warranted by the evidence. Furthermore, as migraine headaches is a disability for which a specific diagnostic code exists under the Rating Schedule, an evaluation by analogy to another diagnostic code section is not appropriate in this case; therefore, there is no other diagnostic code which could potentially provide a basis for the assignment of more that the 10 percent evaluation which is currently assigned. Therefore, the Board finds that the 10 percent rating initially assigned to the veteran's service-connected joint migraine headaches was proper, and the assignment of a higher rating is not warranted. B. Joint space narrowing at L5-S1 The only post-service evidence relevant to the severity of the veteran's joint space narrowing at L5-S1 is the report of a VA spine examination conducted in December 1997. At that time, the veteran complained of low back pain approximately once per week, which began in his low back and extended down his right leg to the knee. He stated that the pain was worse with driving. He reportedly took over-the-counter medications for treatment of this pain, and did not wear a brace. On physical examination, the patient reported minimal pain upon palpation of his spine and paraspinal muscles. Examination of the lower extremities showed 5/5 motor strength bilaterally, and 2+ reflexes at the knee and ankle, which were equal bilaterally. He had intact sensation in the bilateral lower extremities to light touch. Both straight leg raising and femoral nerve stretch tests were negative. Flexion was reported to be from 0 to 100 degrees, extension was to 20 degrees, lateral bending was to 45 degrees, and lateral rotation was to 45 degrees. The examiner reported that there was minimal pain with palpation of the spine and paraspinal muscles. X-rays showed some joint space narrowing at L4-5, but otherwise the alignment was intact with no evidence of degenerative changes. The examiner's impression was as follows: The patient has mechanical low back pain with some evidence of degeneration of disc at L4-5. The patient does not have clinical symptoms consistent with L4-5 nerve root pain. At this point, I would determine that the patient has mechanical low back pain. His pain only occurs about one time per week. He has good range of motion and strength. I would determine that this is a mild disability. The veteran's low back disorder has been evaluated as 10 percent disabling under the provisions of DC 5293, pursuant to which the severity of intervertebral disc syndrome is rated. Under this code, a 10 percent rating is warranted for intervertebral disc syndrome which is mild in severity. If such disorder is moderate, with recurring attacks, a 20 percent rating is warranted. If it is severe, with recurring attacks and only intermittent relief, a 40 percent rating is warranted. Finally, a 60 percent disorder is warranted when intervertebral disc syndrome is pronounced, with persistent symptoms compatible with sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk or other neurological findings appropriate to the site of the diseased disc, with little intermittent relief. A review of the evidence detailed above reveals that the veteran's disc space narrowing is no more than mild in severity. The only relevant post-service medical evidence, i.e., the December 1997 VA examination report, indicates that the veteran's lower extremities have full strength, almost normal range of motion, and normal sensation, and that straight leg raising and femoral nerve stretch test results were both normal. Furthermore, the examiner stated that the veteran did not have symptoms compatible with any nerve root involvement, and x-rays showed no degenerative changes or abnormal alignment. The only medical evidence of any abnormality was the x-ray evidence of joint space narrowing at L4-5, which the veteran reported caused low back pain approximately once per week, with some radiation into the right leg. The examiner stated that, in his opinion, this disability was "mild" in nature. The Board finds that this symptomatology more closely corresponds to the mild level of severity contemplated by a 10 percent rating under DC 5293. This conclusion is buttressed by the fact that the veteran reported that his low back pain only occurred about once per week, and was treated with over-the-counter medications. Examining the evidence summarized above, and giving due consideration to the provisions regarding painful motion under 38 C.F.R. §§ 4.40, 4.59 (see also DeLuca v. Brown, 8 Vet. App. 202 (1995)), the most current medical evidence shows no objective evidence that moderate low back impairment is demonstrated. Given the relative lack of objective findings, and in particular the lack of evidence of any neurological findings or manifestations, the Board finds that the veteran's disorder is not "moderate" in severity, and therefore a 20 percent rating is not warranted by the evidence. While the December 1997 VA examiner indicated that there was minimal pain with palpation of the veteran's spine and paraspinal muscles, there is no objective evidence of additional functional impairment due to such. This fact coupled with the absence of medical findings of atrophy or loss of muscle strength or of symptoms compatible with sciatic neuropathy compels the conclusion that moderate low back disc impairment under Diagnostic Code 5293 is not shown. The Board has considered whether the veteran's low back disorder warrants a higher rating under other related code sections. However, there is no evidence that the veteran meets the criteria for higher evaluations under DC 5292 (limitation of motion), or DC 5295 (lumbosacral strain). Similarly, absent evidence of neurological involvement, the application of codes which contemplate nerve impairment, such as DC 8721, pursuant to which the severity of neuralgia of the sciatic nerve is evaluated, is not warranted. Therefore, the Board finds that the 10 percent rating initially assigned to the veteran's service-connected joint space narrowing at L5-S1 was proper, and the assignment of a higher rating is not warranted. C. Conclusion The Board would point out that its denial of both of the instant increased rating claims is based solely upon the provisions of the VA's Schedule for Rating Disabilities. In Floyd v. Brown, 9 Vet. App. 88, 96 (1996), the Court held that the Board does not have jurisdiction to assign an extra- schedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b)(1) (1999) in the first instance. In this appeal, however, there has been no showing that the disabilities under consideration have caused marked interference with employment (i.e., beyond that contemplated in the assigned evaluation) or necessitated frequent periods of hospitalization so as to render the schedular standards inadequate and to warrant assignment of an extra-schedular evaluation. Although the veteran has stated that he has had to leave work on some occasions because of his headaches, the evidence does not indicate that this has occurred so frequently as to have interfered markedly with his employment. In the absence of such factors, the Board is not required to remand these matters to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Evidence of a well-grounded claim having not been submitted, service connection for bilateral carpal tunnel syndrome is denied. The 10 percent disability rating initially assigned for the veteran's migraine headaches was proper, and thus a rating in excess of 10 percent is denied. The 10 percent disability rating initially assigned for the veteran's joint space narrowing at L5-S1 was proper, and thus a rating in excess of 10 percent is denied. S. L. KENNEDY Member, Board of Veterans' Appeals