Citation Nr: 0006834 Decision Date: 03/14/00 Archive Date: 03/17/00 DOCKET NO. 98-09 252 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Entitlement to an evaluation in excess of 30 percent for service-connected intervertebral disc syndrome of the cervical spine. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The veteran and his spouse ATTORNEY FOR THE BOARD J.M. Daley, Associate Counsel INTRODUCTION The veteran had active service from August 1938 to September 1945, and from March 1956 to February 1959. This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 1998 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which denied an evaluation in excess of 30 percent for service-connected intervertebral disc syndrome of the cervical spine. FINDING OF FACT The veteran's cervical spine disability is manifested by limitation of motion, sensory impairment and complaints of pain with activities, without competent evidence of associated radiculopathy or evidence of severe neurologic symptoms with only intermittent relief. CONCLUSION OF LAW The criteria for an evaluation in excess of 30 percent for a service-connected intervertebral disc syndrome have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5290, 5293 (1999). REASONS AND BASES FOR FINDING AND CONCLUSION Factual Background In May 1939, during service, the veteran was hospitalized for acute alcoholism. He was brought in by ambulance in an unconscious state. No evidence of a skull fracture was found at that time, and a muscle and joint examination was normal. A service medical record dated in April 1943 notes a diagnosis of acute myositis in the lumbar region, to be treated with heat and massage. In June 1944, the veteran was noted to be under observation for joint pain in all extremities of two months' duration. All joints appeared normal. The impression was possible rheumatoid arthritis in all joints. A clinical record brief dated in July 1944 notes rheumatoid arthritis of the knees and ankles, cause unknown. Other July 1944 entries reflect complaints relevant to the hands and wrists, as well as the hips, shoulders and elbows. An August 1944 record notes non-suppurative arthritis of the knees and ankles, cause unknown. The separation examination report, dated in September 1945, notes no musculoskeletal defects other than pes planus. In November 1946, at the time of a VA examination, the veteran complained of left shoulder pain and demonstrated crepitus and some limitation of motion. He was diagnosed with myositis of the left shoulder; x-rays showed no arthritis or significant bony abnormalities. In February 1947, the RO established service connection for left shoulder myositis and assigned a 10 percent evaluation, effective September 18, 1945. In a letter dated in October 1947, H. Shanks, M.D., indicated that the veteran's atrophy of the left shoulder muscle had increased and that there was now involvement of the right shoulder muscles. Dr. Shanks stated that such was a neuro-muscular atrophy. A VA examination in February 1948 failed to reveal left shoulder myositis or arthritis or limitation of motion of either shoulder, or of the cervical spine. The veteran had complained of neck and shoulder pain. A February 1948 request for an X-ray examination notes a clinical diagnosis of myositis of the left shoulder which, according to the referring medical officer, "actually seems to be a lower cervical nerve lesion." The X-rays were normal and were noted to show no arthritis. A March 19, 1948 rating decision reduced the veteran's rating to zero percent, effective May 19, 1948, and denied service connection for arthritis. A VA examination report dated in August 1949 notes early minimal osteoarthritis in the neck with nerve root impingement and radiculopathy, as well as a possible cervical ruptured intervertebral disc. A private evaluation report, dated in July 1949, notes a history of in-service pain in the neck and left shoulder, with a subsequent generalized atrophy of the shoulder girdle and arms. The veteran complained of current pain and aching in the midline of the cervical and upper dorsal regions, and some hypesthesia in the fifth finger of the left hand. Examination revealed generalized atrophy of the entire shoulder girdle and pain to palpation to the left of the spinous process and the upper rhomboids. The veteran had a complete range of pain-free shoulder and neck motion. Muscle power in all shoulder groups was deemed adequate and examination of the arms and hands showed no muscle atrophies and no reflex changes. No sensory changes were noted other than over the volar aspect of the left fifth finger. The diagnoses were possible cervical ruptured intervertebral disc; and early minimal osteoarthritis in the neck with nerve root impingement and radiculopathy. X-rays showed minimal arthritic changes in the neck, without gross bony encroachment of the nerve root foramina. A VA examination was conducted in October 1949. The examiner noted the veteran's history, and opined that the veteran had radiculopathy of the cervical plexus, cause undetermined; and a possible ruptured cervical intervertebral disc. The examiner stated that muscle atrophy indicated that C4 to C7 were involved, and that with involvement of the ulnar nerve, C8 and T1 were also involved. A rating decision dated in November 1949 reflects reconciliation of prior shoulder diagnoses, and sets out assigned disability evaluations for intervertebral disc syndrome with radiculopathy and cervical plexus (formerly called arthritis and myositis) as follows: 10 percent from September 18, 1945 to May 18, 1948; zero percent from May 19, 1948 to October 2, 1949; and 20 percent thereafter. A November 1959 rating decision reflects cessation of any rating for disability characterized as intervertebral disc syndrome, from March 12, 1956, to February 17, 1959, based upon the veteran's re-entrance into service. Service medical records from the veteran's second period of service reveal notations that his back was asymptomatic at entrance. Records note complaints of low back pain and upper spine trouble in September 1957. The impression was lumbar strain. In November 1957, thoracic spine pain was noted; the impression was chronic back syndrome. Effective February 18, 1959, at discharge from his second period of service, a zero percent evaluation was assigned to the veteran's cervical spine disability. A VA examination was conducted in April 1975. X-rays showed degenerative changes in the cervical spine, to include disc space narrowing at C5 to C6 and minimal subluxation at C7 to T1. The impression was degenerative joint disease. Also shown were minimal degenerative changes of the left shoulder. Examination revealed some limitation of neck and shoulder motion. Strength of the neck extensors and lateral flexors was stated to be poor. Reflexes in the upper extremities were equal. Sensation in the upper extremities was intact. The diagnoses were arthritis of the cervical spine, thoracic spine and left shoulder, as well as discogenic disease at C5 to C6, and anterior subluxation at C7 to T1. In a rating decision dated in August 1975, the RO increased the evaluation assigned to cervical intervertebral disc syndrome from zero to 20 percent, effective October 16, 1974. In that rating decision the RO set out that "[a]rthritis of the cervical and thoracic spine and lt. shoulder is generalized and is not etiologically related to the intervertebral disc syndrome. The trauma associated with his SC back condition was localized and cannot be considered as an adjunct to the disc syndrome." Thereafter, the veteran requested an increased rating on several occasions; the RO denied an increase in February 1977 and November 1978. In a letter dated in November 1980, Dr. Badke noted that the veteran had degenerative osteoarthritis of the spine, particularly evidence in the cervical spine. Dr. Badke indicated that the veteran's most severe disability was in the upper extremities where he had weakness in the ulnar distribution to both arms and hands. A VA examination was conducted in November 1982. Examination revealed some limitation of cervical spine motion, without atrophy of either shoulder girdle. The veteran demonstrated a full range of motion of all upper extremity joints but an inability to completely elevate his arms over his head. Reflexes were normal and there was no evidence of any sensory changes. X-rays taken in December showed advanced degenerative change of the cervical spine with multiple areas of disc narrowing and neural foraminal encroachment. The diagnoses were bilateral atrophy of trapezius muscles, more on the left than the right with winging of the scapulas, more on the left than the right; and, degenerative changes of the cervical spine with limitation of motion of the spine. VA nerve conduction studies were performed in May 1983 and revealed no evidence of neuropathy or motor root injury. A primarily sensory root lesion was not excluded. At the time of VA examination in February 1988, the veteran complained of severe pain in his neck and left shoulder area. He reported a problem with "slipped discs" in the cervical area occurring with physical activities and stated that he experienced blackouts when that occurred. X-rays showed extensive degenerative disc disease at C3 to C7, with anterior subluxation of C7 to T1. The examiner noted that the veteran dressed and undressed, and put a collar on without any problem in the right shoulder, but with some limited left shoulder motion and tightness in the trapezius muscle bilaterally. In a final decision of December 1989, the Board denied an evaluation in excess of 20 percent. A report of a VA x-ray, dated in May 1990, shows extensive degenerative discogenic disease of the lower cervical spine and osteoarthritis of the facet joins and mild subluxation at C7 to T1. No further changes were shown on x-rays taken in June 1990. In May 1993, the veteran presented testimony at a personal hearing. He complained of difficulty moving his head, and reported pain in his neck and shoulders on such movement. He stated that with quick movement his vertebral bars would pop and he had "passed out many times in the past." He complained of his muscles becoming taught and reported spasm all the time. He also reported accompanying headaches and atrophy of his left shoulder. The veteran also reported occasional numbness depending on his activities. The veteran argued that his symptoms were due to arthritis and that he had always had arthritis, back to service. Transcript. The veteran reported for a VA examination in June 1993. There was no evidence of wasting from behind and shoulder girdle muscles were stated to all be intact and adequate with good tone and function. There was no tenderness to palpation in any of the shoulder girdle areas. There was some tenderness to cervical paraspinal muscles in the lower cervical spine, but without radiculopathies. The examiner noted some limitation of cervical spine motion. Tinel's sign was positive in the right elbow for cubital tunnel or ulnar nerve entrapment at that level. Grip strength was stated to be decreased due to arthritic changes throughout the hand. Electromyography in July 1990 was stated to be normal without evidence of right or left cervical radiculopathy. A VA outpatient record dated in July 1993 reflects that the veteran complained of lower back pain with arm and leg involvement following bending over to tie his shoes on the previous day. The impression was muscle strain, acute/chronic. In May 1995, the RO advised the veteran that his claim for service connection for arthritis had been denied on "March 17, 1938," and that the claim had not been reopened. (This apparently refers to the March 1948 rating decision.) The veteran was advised of the possibility of reopening his claim based on new and material evidence. In June 1996 decision, the Board granted a 30 percent rating for the veteran's intervertebral disc syndrome of the cervical spine. A VA outpatient record dated in August 1996 reflects a diagnosis of carpal tunnel syndrome. Other VA records dated in September 1996 reflect complaints relevant to both shoulders. In October 1996, the veteran complained of neck pain, but reported some relief with the use of a TENS unit. That report includes note of the veteran's use of a carpal tunnel brace. VA outpatient records dated in March 1997 reflect complaints of neck pain, and include note that the veteran used a TENS unit. In May 1997, the veteran again requested an increase in the percentage evaluation assigned to his cervical spine disability. In July 1997, the veteran presented for a VA examination of his spine, at which time he was 80 years of age. The examiner noted the veteran's history of initial injury during service, and that the veteran's neck pain became severe in 1947. The veteran reported that he had to retire in 1978 secondary to chronic neck and shoulder pain. Also, the examiner noted that the veteran was in a motor vehicle accident in March 1996, aggravating his cervical spine and shoulder pain. Thereafter he was treated for whiplash of the neck and tendinitis and bursitis of both shoulders. The examiner noted that the veteran still received cortisone shots in each shoulder about every three to six months, and also noted that the veteran had a history of carpal tunnel syndrome, and it was unknown whether such was related to his cervical spine problem. The examiner stated that the veteran did not have a history of computer use or using his hands besides being a mechanic. At the time of examination in July 1997, the veteran complained of bilateral shoulder pain, right greater than left, and upper neck pain. He indicated that he was able to perform all of his activities of daily living, except that he recently stopped doing yard work because it aggravated his shoulder pain. Examination revealed the right supraspinatus muscle to be more hypertrophied than the left, with a pronounced protrusion of the right upper aspect of the scapula compared with the left. The veteran had full flexion of his cervical spine. His backward extension was limited to 10-to-15 degrees, with bilateral lateral bending to 10 degrees. The veteran had left rotation to 30 degrees and right rotation to 20 degrees. The examiner noted objective evidence of pain upon neck extension and rotation of the neck, right greater than left. There was no evidence of diminished sensation to light touch of either upper extremity. The veteran complained of some difficulty holding things and difficulty with writing. He also reported some occasional shooting pains down his arms, into the fingers. Muscle strength was diminished, right greater than left, in shoulder extension. The veteran was able to abduct both shoulders to 170 degrees using accessory muscles and a great deal of effort. There was evidence of pain with abduction and flexion, as well as with external rotation. X-rays were stated to be similar to 1995 results, but revealed "considerable vascular calcification in the soft tissues of the neck bilaterally which is worse on the right side." The x-ray report states that "when allowing for technical factors, there has been no significant interval change." The diagnoses were chronic degenerative joint disease of the cervical spine secondary to old army injury and exacerbated with recent motor vehicle accident; and chronic subdeltoid tendinitis/bursitis of each shoulder secondary to recent vehicle accident trauma. In September 1998, the veteran testified at a personal hearing. He reported that his cervical spine disability affected his ability to lift things and made him unable to drive due to back spasm on turning his head. He also described pain going down his arms, and stated that he had difficulty holding things without dropping them. Transcript. In October 1998, R. Moody, II, M.D., examined the veteran for the VA. The veteran reported constant neck pain, increasing with weather changes, stress, working and driving. He indicated that he had nightly flare-ups and that he popped his spine for relief, along with taking painkillers. It was noted that he could not state how long flare-ups lasted. He reported a history of pain, weakness, fatigue and functional loss associate with pain. He also reported stiffness, fatigability and deceased endurance. Physical examination revealed no fix or drift. Strength was 5/5 in the proximal and distal upper extremity muscle groups. There was apparent wasting of the interosseous muscles especially in the left hand. Reflexes were 2+ in the upper extremities, 1+ at the knees and 0 at the ankles. Sensation was symmetric in the upper extremities. Dr. Moody noted that there was no specific evidence of cord disease on examination but noted that the veteran had progressive difficulty with balance and findings "which could very well be suggestive of spinal cord disease on the basis of cord compression in the neck." Dr. Moody noted that there were no specific changes to corroborate such on physical examination and stated that mild distal wasting of the interosseous muscles of the left hand was most likely secondary from polyneuropathy or ulnar neuropathy. Dr. Moody further reported that cervical spine motion produced pain when the end point of motion was reached, stating that there was no apparent additional limitation by pain, weakness, fatigue or endurance. Also, there was no objective evidence of painful motion, spasm, weakness or tenderness. There was increased cervical kyphosis, but musculature of the cervical spine was normal. After undergoing diagnostic studies the veteran was seen by Dr. Moody in October 1998, at which time he noted that electromyography (EMG) and nerve conduction velocity studies showed evidence of a mild neuropathy in the upper extremities, consistent with mild axonal sensorimotor polyneuropathy, with no evidence of cervical radiculopathy. Dr. Moody noted that he found no evidence of cervical radiculopathy, plexus lesion or proximal entrapment. The report of an X-ray examination indicates that the C3 to C4, C5 to C6 and C6 to C7 disc spaces were severely narrowed, with Grade 1 spondylolisthesis at C7 to T1. The impression was advanced degenerative changes. The clinical diagnoses made by Dr. Moody were cervical degenerative joint disease with spondylolisthesis; evidence of polyneuropathy on physical examination; and symptoms of cervical radiculopathy, with EMG negative for radiculopathy. Magnetic Resonance Imaging was recommended to rule out cord compression. In December 1998, the veteran underwent a VA examination. It was noted that he had a pacemaker and that that was the reason he did not go for his MRI. The veteran's spouse indicated that the veteran had trouble walking and dropped coffee cups and things in his hands. On examination of the neck, the examiner could feel the spondylolisthesis described in x-rays. The veteran was able to rotate 60 degrees to his left and 30 degrees to his right. He had lateral bending to no more than 10 degrees. He had about 60 degrees of combined flexion and extension but in a sitting position his neck was held in about 30 degrees of flexion. The neck was straight and forward; there was tenderness. Examination of the upper extremities revealed some spotty numbness involving the ulnar distribution and a bit in the radial and ulnar distribution not following a radicular pattern. There was significant atrophy of the interosseus muscles of the hands. The examiner indicated that the veteran certainly had severe osteoarthritis of the neck with spondylolisthesis and a decreased range of motion but that the source of the neurologic deficit was difficult to identify. The examiner further noted that it seemed to be a problem involving the entire body in that the veteran's legs were weak and he lacked coordination there. The examiner also noted that the veteran's grasp strength was 40 pounds on the right and 20 pounds on the left. The impression was peripheral nerve deficit which did not seem to be related to the neck. The examiner concurred that MRI was not a good idea but that there was no reason "not to get at least a CAT scan. Since the source of his neurologic deficit is unknown, I feel that he deserves benefit of a doubt and should have a CAT scan which is non-invasive and would not be a problem with his pacemaker." A December 1998 examination report by Dr. Moody indicates that he reviewed the veteran's medical records. The veteran was noted to report upper extremity grip difficulty. Dr. Moody stated that the veteran did not have evidence of cervical radiculopathy or associated muscle spasm. Grip strength was stronger on the right than the left at various settings on a dynamometer. It was noted that the examination was unchanged from the prior evaluation in October. Pertinent Regulations Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Schedule), 38 C.F.R. Part 4 (1999). The percentage ratings contained in the Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (1999). In determining the disability evaluation, the VA has a duty to acknowledge and consider all regulations which are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Governing regulations include 38 C.F.R. §§ 4.1, 4.2 (1999), which require the evaluation of the complete medical history of the veteran's condition. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). All benefit of the doubt will be resolved in the veteran's favor. 38 C.F.R. § 4.3 (1999). Slight limitation of motion of the cervical spine warrants a 10 percent rating, moderate limitation of motion warrants a 20 percent rating and severe limitation of motion warrants a 30 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5290. 38 C.F.R. § 4.71a, Diagnostic Code 5293, provides a (maximum) 60 evaluation for intervertebral disc syndrome of pronounced degree 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 40 percent evaluation is warranted for a severe disorder characterized by recurring attacks with intermittent relief. A 20 percent evaluation is for moderate symptoms and recurring attacks. A 10 percent evaluation requires mild symptoms and a zero percent rating is for a post-operative, cured condition. 38 C.F.R. § 4.71a, Diagnostic Code 5285 provides that residuals of a vertebral fracture warrant a 100 percent rating with cord involvement, when the veteran is bedridden or requires long leg braces. With lesser involvements, the residuals are to be rated for limited motion, nerve paralysis. Without cord involvement but with abnormal mobility requiring neck brace (jury mast), a 60 percent rating is provided. Disability of the musculoskeletal system is the inability to perform normal working movement with normal excursion, strength, speed, coordination, and endurance, and that weakness is as important as limitation of motion, and that a part which becomes disabled on use must be regarded as seriously disabled. However, a little-used part of the musculoskeletal system may be expected to show evidence of disuse, through atrophy, for example. 38 C.F.R. § 4.40. The provisions of 38 C.F.R. § 4.45 and 4.59 contemplate inquiry into whether there is crepitation, limitation of motion, weakness, excess fatigability, incoordination, and impaired ability to execute skilled movements smoothly, and pain on movement, swelling, deformity, or atrophy of disuse. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing are also related considerations. It is the intention of the rating schedule to recognize actually painful, unstable, or mal-aligned joints, due to healed injury, as at least minimally compensable. Id. The United States Court of Appeals for Veterans Claims (known as the United States Court of Veterans Appeals prior to March 1, 1999) (hereinafter, "the Court"), in DeLuca v. Brown, 8 Vet. App. 202 (1995), held that where evaluation is based on limitation of motion, the question of whether pain and functional loss are additionally disabling must be considered. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (1999). It has been held that consideration of functional loss due to pain is not required when the current rating is the maximum disability rating available for limitation of motion. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). However, consideration of additional functional loss is mandated where the veteran is evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5293, pertaining to intervertebral disc syndrome, even where the assigned rating is the maximum under applicable limitation of motion codes. See VAOPGCPREC 36-97 (December 12, 1997). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14 (1999). It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Analysis The veteran is service-connected for intervertebral disc disease of the cervical spine, and is currently in receipt of a 30 percent evaluation under Diagnostic Code 5293-5290. 38 C.F.R. § 4.27 (1999) provides that hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. The 30 percent evaluation currently assigned to the veteran's cervical spine disability is the maximum available evaluation under Diagnostic Code 5290, based on severe limitation of motion of the cervical spine. Although Diagnostic Code 5293, pertaining to intervertebral disc syndrome, provides for higher evaluations of 40 and 60 percent, those evaluations are awarded for severe or pronounced, respectively, intervertebral disc syndrome with symptoms such as spasm, radiculopathy or other neurologic findings appropriate to the site of the diseased disk, and from which there is only intermittent (40 percent) or little intermittent (60 percent) relief. The reports of examination dated in October and December 1998, performed by a VA physician and by Dr. Moody for VA, respectively, are the most probative evidence of record in this case. See Francisco, supra. Despite the veteran's complaints of weakness, numbness and dropping things, as well as pain and spasm in the neck and upper extremities, the examination reports do not note clinical evidence of cervical radiculopathy or spasm. In fact, testing was specifically negative for cervical radiculopathy, as was earlier testing, the results of which are shown in the record. The noted peripheral nerve deficit was opined to be unrelated to the veteran's neck problems, and the examiners indicated a more global problem affecting both upper and lower extremities. Moreover, the veteran has carpal tunnel syndrome, which has not been related to his service-connected cervical disability and for which he is not service-connected. Manifestations associated with nonservice-connected carpal tunnel syndrome and/or peripheral neuropathy cannot be considered in assigning the veteran's service-connected disability a percentage evaluation under the Schedule. See 38 C.F.R. § 4.14. Thus, based on the absence of clinical evidence of spasm, radiculopathy or other severe or pronounced neurologic symptoms, no higher evaluation is warranted under Diagnostic Code 5293. The Board notes the VA General Counsel opinion holding that functional loss must be considered in connection with Diagnostic Code 5293. See VAOPGCPREC 36-97 (December 12, 1997). However, in this case, the October 1998 examiner specifically opined that there was no apparent additional limitation due to pain, weakness, fatigue or endurance, and no objective evidence of painful motion, spasm, weakness, or tenderness, noting only that cervical spine motion produced pain when the end point of motion was reached. Prior medical evidence does not contain the conclusion that the veteran suffered additional functional loss beyond that contemplated in the current record. Although the July 1997 examination report notes some atrophy and the veteran's complaints of weakness, etc., the examiner indicated that the veteran's recent automobile accident aggravated his complaints. Thus, the more recent examination reports are more probative of the status of the veteran's service-connected condition. Also, although the veteran has complained of pain, particularly with motion, such complaints are contemplated in his assigned 30 percent evaluation. He has reported difficulty moving his neck and experiencing neck and upper extremity pain with certain movements, as well as some sensory loss. The 30 percent evaluation, under Diagnostic Code 5290, contemplates severe motion loss with functional impact, and Diagnostic Code 5293 provides a 20 percent evaluation for a moderate intervertebral disc syndrome with recurrent attacks. Notably, despite his complaints in July 1997, the veteran reported that he was able to perform all activities of daily living, with the exception of a recent cessation of yard work due to exacerbation of his shoulder pain. The Board also notes that the veteran has reported some relief of his symptoms with the use of therapeutic measures such as a TENS unit. Although the veteran has described additional symptoms such as dropping items and having problems with his wrists, the Board again notes that he is not service-connected for carpal tunnel or for peripheral neuropathy, which have not been related by competent medical evidence to his service- connected cervical spine disability. As such, the competent medical evidence does not demonstrate that the symptoms attributable to the service-connected cervical disability are sufficient to warrant an increased evaluation under Diagnostic Code 5293, or upon application of 38 C.F.R. §§ 4.40, 4.45, 4.59. Inasmuch as the veteran can not undergo MRI because of an implanted cardiac devise, it was recommended that he be afforded a CAT scan. It does not appear that such was undertaken. However, inasmuch as the Board is not attempting to limit the rating for the cervical spine disability by dissociating the service-connected manifestations from any that might be attributable to related spinal cord pathology, if any, the results of a CAT scan are not necessary to rate the disability. The veteran's service-connected disability clearly does not encompass a vertebral fracture; nevertheless, considering it under the provisions of Diagnostic Code 5285 would not provide a basis for a higher rating. Were a CAT scan to show cord involvement, the cervical spine disability would still be rated on limitation of motion since it does not cause the veteran to be bedridden, does not necessitate long leg braces, is not manifested by abnormal mobility requiring a neck brace (jury mast), and is not shown to be manifested by nerve paralysis. 38 C.F.R. § 4.71a, Diagnostic Code 5285. Accordingly, it is not necessary to remand the case for a CAT scan. Consideration has also been given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4 (1999), whether or not they were raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, the Board finds no basis upon which to assign a higher disability evaluation. To the extent the veteran argues that he has related cervical spine arthritis causing disability, he is not service-connected for arthritis. Thus, symptoms attributable to arthritis cannot be considered in evaluating his service-connected disability. See 38 C.F.R. § 4.14. In any case, the 30 percent assigned evaluation is in excess of the percentage available under 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010 (1999), pertaining to arthritis, and inasmuch as arthritis is otherwise rated based on motion limitation, separate evaluations would in no case be warranted. See 38 C.F.R. § 4.14. Additionally, the Board does not find that consideration of an extraschedular rating under the provisions of 38 C.F.R. § 3.321(b)(1) is in order. The evidence in this case fails to show that the veteran's cervical spine disorder, in and of itself, now causes or has in the past caused marked interference with his employment, or that it has required frequent periods of hospitalization rendering impractical the use of the regular schedular standards. Id. The veteran does argue that the severity of his cervical spine disorder affects his ability to operate a motor vehicle. He and his spouse also argue that he is physically limited from activities such as doing yard work. However, the currently assigned 30 percent evaluation contemplates the limited motion, pain and other symptoms of the cervical spine disability, which are the very symptoms resulting in the veteran's physical limitations. The Board notes that 38 C.F.R. § 4.1 specifically states that "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." What the veteran has not shown in this case is that his cervical spine disability requires frequent hospitalization or surgery, or that, in and of itself, it results in unusual disability or impairment that renders the criteria and/or degrees of disability contemplated in the Schedule impractical or inadequate. Accordingly, consideration of 38 C.F.R. § 3.321(b)(1) is not warranted. As the evidence is not in equipoise, but rather is preponderantly against an increase in this case, the benefit of the doubt and 38 C.F.R. § 4.7 are not for application. ORDER An evaluation in excess of 30 percent for a service-connected cervical spine disability is denied. JANE E. SHARP Member, Board of Veterans' Appeals