BVA9500797 DOCKET NO. 93-07 466 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to an increased evaluation for right thoracic outlet syndrome, currently evaluated as noncompensable. 2. Entitlement to an increased evaluation for left thoracic outlet syndrome, status post resection of the first cervical rib, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: AMVETS ATTORNEY FOR THE BOARD M. M. Wernimont, Associate Counsel REMAND The veteran 's active military service extended from November 1970 to November 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 1992 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. That rating decision granted service connection for the following: right (major) thoracic outlet syndrome, for which a noncompensable disability evaluation was assigned; and left thoracic outlet syndrome, status post resection of the first cervical rib, for which a 20 percent disability evaluation was assigned. According to the service medical records, beginning in the early 1980's, the veteran experienced pain in the neck, upper extremities, bilaterally, and a "tingling" sensation of the fingers. In December 1988, while in the military, she underwent a resection of the left first rib, and the assessment was status post left thoracic outlet syndrome. At a January 1992 VA examination conducted for purposes of evaluating the veteran's disabilities, the examiner noted that the resulting disability of the veteran's arms after surgery, might bring into question the possibility of some other cause of the pain such as osteoarthritis of the cervical spine. The examiner recommended radiographic studies of the cervical and lumbosacral spine, which were conducted, and then vascular studies of the right and left arms. A VA Vascular Consult dated in January 1992, during which pulse volume recording wave forms of the veteran's upper extremities were conducted, resulted in a diagnosis of probable thoracic outlet syndrome on the left, and a recommendation that an appointment be made for the veteran at a VA Vascular Clinic. A report of a July 1992 VA neurologic examination indicates that the claims file was not made available to the examiner resulting in the examiner not having a complete history of the veteran's neurovascular disorder, diagnosed as bilateral thoracic outlet syndrome. The report shows that the veteran provided the examiner with a history that she had initially experienced bilateral shoulder and hand pain, as well as neck pain in approximately 1986 while she was in the military. She also reported that she underwent surgery to remove part of a left rib. During the examination, the veteran also stated that electromyogram, nerve conduction velocities and radiographic studies may have been conducted. However, the VA neurologic examination in July 1992 was conducted without the physician having the earlier medical records available. The diagnosis was normal neurologic examination. The examiner stated that the question of thoracic outlet syndrome would be approached after review of the necessary medical materials, which would include the following: radiologic studies of the veteran's cervical spine, including a Computerized Axial Tomography (CT) scan and flat films of electromyogram and nerve conduction velocities bilaterally in the ulnar, median and radial nerves. An addendum dated in August 1992 and written by the same VA neurologist stated that it was very probable that the tests were in a "missing" claims folder. In a second addendum dated that day, the VA neurologist stated that because the diagnosis of thoracic outlet syndrome, had been properly made on the basis of symptomatology consisting of pain in the thoracic outlet region with limitation of strength or limitation of motion, and with no objective neurologic proof, he considered it unnecessary to perform the above-mentioned tests. The final diagnosis was thoracic outlet syndrome, postoperative. Based upon the examination report, a rating decision dated in November 1992 confirmed and continued the veteran's prior disability evaluations. A letter dated in January 1993 from the Disability Determination Service of the Arizona Department of Economic Security to the RO reveals that the veteran had filed claims for disability benefits, pursuant to the provisions of the Social Security Act and the Arizona Long-Term Care System. A review of the file indicates that appellate disposition of the veteran's claims would be premature. To ensure that the Department of Veterans Affairs (VA) has met its duty to assist the claimant in developing the facts pertinent to the claim and to ensure full compliance with due process requirements, the case is REMANDED to the RO for the following development: 1. The RO should request the service department to make a search for any additional service medical records that may be on file for the veteran. After such service medical records have been obtained, they should be added to the claims file. 2. The RO should contact the veteran and obtain the names and addresses of all medical care providers, VA and private, inpatient and outpatient, especially those who treated the veteran for both right and left thoracic outlet syndrome after service separation in November 1990, including the dates of such treatment, and the results of all tests, studies and analyses conducted. After obtaining the necessary information and securing the necessary releases, the RO should obtain photocopies of these records and add them to the claims file. 3. The RO should obtain from the Arizona Department of Economic Security - Disability Determination Service; P. O. Box 11980; Phoenix, Arizona 85061, the records pertinent to the appellant's claim for Social Security disability benefits and the records pertinent to her claim for benefits under the Arizona Long-Term Care System, as well as the medical records relied upon concerning those claims. 4. Thereafter, the veteran should be scheduled for special VA neurovascular and orthopedic examinations (including radiographic studies) to determine the nature and extent of all pathology of the veteran's neck, upper extremities and back, including the nature and extent of right thoracic outlet syndrome and of left thoracic outlet syndrome, status post resection of the first cervical rib. The examinations should be conducted in accordance with the Physician's Guide for Disability Evaluation Examinations, and all indicated tests and studies should be completed, with the findings reported in detail. The examining physicians should be asked to provide medical opinions regarding the etiologies of all abnormalities of the veteran's neck, upper extremities and back and whether they are part of or the result of the service connected disabilities. The claims file and a copy of the Remand must be made available to the examiners for study prior to the examinations, so that they are aware of the complete history of the veteran's related symptomatology and treatment prior to rendering diagnoses and offering medical opinions. The reports should be comprehensive and should include full rationale for all opinions expressed. 5. Subsequently, the RO should review the examination reports and determine whether they are adequate for rating purposes and in full compliance with this Remand. Any report that is not should be returned to the examiner for corrective action. After the development requested above has been completed to the extent possible, the RO should again review the record. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the appellant and her representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant need take no action unless otherwise notified. JOAQUIN AGUAYO-PERELES 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. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).