BVA9504577 DOCKET NO. 92-09 034 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Wichita, Kansas THE ISSUES Entitlement to service connection for a low back disability manifested by traumatic arthritis and lumbar radiculopathy. Entitlement to service connection for a neck disability manifested by cervical radiculopathy. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Hilary L. Goodman, Counsel INTRODUCTION The veteran had active service from August 1989 to August 1990. This appeal arises from a March 1991 rating decision which denied service connection for low back and neck disabilities. The Board of Veterans' Appeals (Board) previously remanded the veteran's case to the originating agency in March 1993. The appeal was returned to the Board in December 1994. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he sustained low back and neck injuries while serving aboard ship which caused residual disability. He asserts that one injury occurred while moving a cable and that he was also injured when a chain fell on his neck, resulting in right-sided pain of the neck and shoulder. He further asserts that treatment for the latter injury included a cervical collar. He requests service connection for the resulting low back and neck disabilities. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the record supports the veteran's claim for service connection for a low back disability manifested by traumatic arthritis and lumbar radiculopathy and a neck disability manifested by cervical radiculopathy. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the originating agency. 2. The veteran sustained injuries to the neck and low back during active service. 3. Facet degenerative joint disease of the lumbar spine and lumbar radiculopathy as well as his cervical radiculopathy have been diagnosed and may not be dissociated from his injuries in service. CONCLUSIONS OF LAW 1. The veteran's low back disability manifested by facet joint disease and lumbar radiculopathy was incurred in service. 38 U.S.C.A. §§ 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1993). 2. The veteran's neck disability manifested by cervical radiculopathy was incurred in service. 38 U.S.C.A. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran is seeking service connection for low back and neck disabilities. After reviewing the record, the Board finds that his claims are plausible; therefore, they are well grounded within the meaning of 38 U.S.C.A. § 5107(a). The Board is also satisfied that all relevant facts have been properly developed and no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). The service medical records reflect that on examination of the veteran in November 1988 for entry into service, his spine and musculoskeletal system were normal and he was found to be neurologically normal. A reference he made to whiplash due to a "car wreck" was crossed out. A physician's comment dated in July 1989 refers to an auto accident in 1987 which had required treatment with valium and motrin for several weeks. Service clinical records show that in January 1990 he was seen for complaints of back and neck pain which had been present for one week. He related that he was moving cable up a ladder when the cable pulled around his neck. He reported that the neck pain would shoot down his right shoulder when he turned his neck and that, when he bent over, the pain would shoot from his lower back down both legs. On examination, there was decreased range of motion of the neck, he grimaced when returning from the prone position to sitting and there were spasms of the neck and low back, bilaterally. The assessment was low back strain. In April 1990 the veteran was seen for complaints of pain of the right side of the neck and shoulder. He indicated that a chain weighing approximately twenty pounds had fallen on his neck and that, in addition to the pain, he was having difficulty moving his right arm. On examination there was swelling with ecchymosis of the right side of the neck and there was tenderness to palpation over the area of the neck to the back of the right shoulder and the front of the chest. The assessment was trauma to the right side of the neck, contusion. A cervical collar was applied. He was admitted for observation. At the time of the veteran's August 1990 separation examination, his complaints included low back pain. No diagnosis of a neck or low back disability was made. The Department of Veterans Affairs (VA) conducted an orthopedic examination of the veteran in November 1990. It was noted that the veteran had significant complaints involving his low back and neck, including tightness, poor mobility and pain. He related that he had considerable stiffness in the back and neck for about one hour upon awakening in the morning and that it was associated with pain. On examination, he heel and toe walked well, had full strength of the upper and lower extremities and sensation was completely intact in the upper and lower extremities. There was some limitation of motion of the cervical and lumbar spines. The assessment was considerable low back and neck stiffness and pain. It was noted that, because of the veteran's clinical severity, it seemed necessary to rule out inflammatory spondyloarthropathies. It was indicated that X-rays were within normal limits but that he might be in the early stages of these diseases. A neurologic examination of the veteran was conducted by the VA in July 1994. The veteran related that he had been experiencing intermittent pain over the back of his neck since 1989, after suffering a neck injury. The pain could be elicited by turning his head to the left and it then might radiate to the right shoulder and lateral aspect of the right arm. He reported that he had experienced episodic low back pain ever since falling down a ladder in 1990. The low back pain could be elicited or enhanced by walking long distances, bending over, lifting or a change in the weather to rain. At times, the low back pain radiated to the lateral aspect of the left thigh. On examination, there was tenderness over the back of the neck at the fourth to seventh cervical vertebral level. The veteran had decreased sensation to light touch and pinprick over the lateral aspect of the right arm. Bulk, tone and power were within normal limits over the upper extremities and there was no evidence of muscle wasting or muscle weakness. There was tenderness of the lumbosacral joint and over the left sciatic distribution. There was decreased sensation to light touch and pinprick over the lateral aspect of the left thigh. Straight left leg raising was positive at fifty degrees. Power of the extensor hallucis longus was four out of five on the left and five out of five on the right. He had some difficulty in heel walking. The examiner noted that the impression following X-ray examinations of the cervical and lumbosacral spines was no gross abnormality. The diagnoses were history of episodic pain over back of neck; right fifth cervical vertebra radiculopathy; history of episodic low back pain; and left fifth lumbar vertebra radiculopathy. Later the same month the VA conducted computerized tomography (CT) scans of the veteran's cervical and lumbar spines. The CT scan of the lumbar spine revealed minimal hypertrophic facet arthropathy without associated lateral recess stenosis. There was no evidence of a herniated disk or spinal stenosis. The impression was minimal facet degenerative joint disease. On CT scan of the cervical spine, there was no evidence of a herniated disk. In August 1994, the VA performed electromyographic testing of numerous muscle groups, including of the veteran's upper and lower extremity extremities and nerve conduction velocity testing of the upper extremities. The results were found to be within normal limits. Another examination of the veteran was conducted by the VA in August 1994. The examiner noted that he reviewed the CT scans and X-ray films. He indicated that he agreed with the previous interpretations, including the finding of minimal facet degenerative joint disease on the lumbar CT scan. In the history given by the veteran he noted that he had not had any low back or neck injuries either previous or subsequent to service. On examination of his neck, there were no muscle spasms. He complained of mild tenderness to palpation of the posterior cervical muscles and the right posterolateral muscles. The examiner noted that he did not find any neurological deficit of the right upper extremity. There were no muscle spasms of the low back. The veteran complained of significant tenderness to palpation of the lower lumbar spine. The lumbar muscles to either side were slightly tender. Range of motion testing of the lumbar spine caused complaints of increased low back pain. Pinprick sensation in the lower legs was normal and equal. Straight leg raising in a sitting position was negative at ninety degrees, bilaterally. The examiner concluded that the physical examination did not show evidence of any nerve injuries or deficit of the upper or lower extremities. The Board, after reviewing the entire record, has determined that there is an approximate balance of positive and negative evidence with respect to whether the veteran currently has neck and low back disabilities which are related to the injuries he sustained in service. While there is reference to a pre-service auto accident on the entry examination, no pertinent findings were reported and the presumption of soundness applies. Considering this, and the requirement that benefit of the doubt must be given to the veteran, the Board concludes that service connection should be granted for a low back disability manifested by bony changes of the facets and lumbar radiculopathy and a neck disability manifested by cervical radiculopathy. 38 U.S.C.A. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.304. ORDER Entitlement to service connection for a low back disability manifested by traumatic arthritis and lumbar radiculopathy and to a neck disability manifested by cervical radiculopathy are awarded. ROBERT D. PHILIPP Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), 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 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.