BVA9506388 DOCKET NO. 93-09 617 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for residuals of a cervical spine injury. 2. Entitlement to an increased evaluation for low back strain with a collapsed disc space, currently evaluated as 40 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD Robert P. Regan, Counsel REMAND The appellant served on active duty from November 1942 to April 1947 and from October 1961 to September 1962. The appellant also had service with the U.S. Air Force Reserve from August 1961 to August 1964, with the Army National Guard of South Carolina from September 1964 to September 1966, April to July 1969, and with the U.S. Army Reserve from November 1973 until his retirement therefrom in March 1984. A review of the record reflects that there are no service medical records on file pertaining to the appellant's duty with the Army National Guard, Air Force Reserve or Army Reserve, except for medical records dated in July and August 1982. During the appellant's April 1993 hearing before the undersigned, member of the Board of Veterans' Appeals (Board) in Columbia, South Carolina, he indicated that he had been treated in the 1980's, following the injury to the cervical spine, by private physicians. He stated that he was unsure of their names, but believed that the treatment was received from Drs. Black and Leonard. He indicated that Dr. Leonard was deceased, and that Dr. Black was retired. He stated that he believed a medical organization may have possession of Dr. Leonard's records, but did not identify the medical facility. Also during his hearing, he gave testimony tending to indicate that there had been an increase in symptomatology associated with his service-connected low back disorders. In a release of information form, received in January 1990, he indicated that he had received treatment at a VA medical facility in Columbia, South Carolina, beginning in 1980. In a December 1992 statement from his representative, it was indicated that he had been seen for treatment at the VA Outpatient Clinic in Greenville, since June 1991. With regard to the appellant's claim of service connection for residuals of an injury to the cervical spine, following a June 1992 VA examination, a VA examiner commented that the appellant had recently been involved in a motor vehicle accident and that degeneration was present in the cervical spine which radiographically and clinically confirmed was part of a longstanding process. The examiner further indicated that it was impossible to predict whether or not the appellant would have progressed to such severe degenerative disease in the cervical spine had it not been for a motor vehicle accident in 1982. However, the examination report does not indicate that the examiner reviewed the appellant's claims folder, particularly the treatment records and X-ray report relative to the July 1982 accident. The examiner makes no reference to the arthritic disorder involving the cervical spine which was radiographically confirmed at that time. The Board is of the opinion that a contemporaneous and thorough VA examination would be of assistance to the Board in rendering a determination in this case. Caffrey v. Brown, 6 Vet.App. 377 (1994). In accordance with the statutory duty to assist the appellant in development of evidence pertinent to his claim, the case is REMANDED for the following actions: 1. The RO should make another attempt to secure through official channels all medical records pertaining to the appellant's service in the Air Force Reserve, Army National Guard of South Carolina, and the Army Reserve, including his period of active duty from October 1961 to September 1962. A copy of his statement of service, dated in May 1984, and received into the record on July 31, 1991, should accompany the request. 2. The RO should furnish the appellant the appropriate release of information forms in order to obtain private medical records pertaining to treatment for the residuals of the injury to the cervical spine subsequent to July 1982, to include the medical facility where the appellant believes Dr. Leonard's medical records may be located. The RO should also obtain copies of all medical records from the Spartanburg Regional Medical Center, where the appellant is being treated on a fee basis, covering the period from June 1992 up to the present. 3. The RO should obtain copies of medical records not already of record from the VA Medical Center in Columbia, South Carolina, and the VA Outpatient Clinic in Greenville, covering the period from 1980 up to the present. 4. The appellant should be afforded a VA orthopedic examination to determine the nature and severity of his service- connected low back strain with disc collapse and any disability involving the cervical spine. All testing deemed necessary should be performed. It is requested that the orthopedist include the specific degrees of range of motion of the cervical and lumbosacral spine and the degrees which constitute normal range of motion of the lumbosacral spine. The claims folder should be made available to the examiner for review in conjunction with the examination. In conjunction with a review of the claims folder, it is requested that the examiner render the following opinions: (a) Was the degenerative arthritis, detected by X-ray studies in July 1982 in conjunction with the whiplash injury the appellant sustained in July 1982, a result of the whiplash injury or was the degenerative arthritis present prior to that whiplash injury? (b) If the degenerative arthritis involvement of the cervical spine predated the July 1982 whiplash injury, did the whiplash injury result in an increase in disability of the degenerative arthritic process of the cervical spine beyond natural progress of the disease? (c) Are there any identifiable pathological findings currently shown which are attributable to, or a manifestation of, the whiplash injury which occurred in July 1992? The rationale for the opinions requested above should be included in the written examination report. 5. A VA neurological evaluation should be performed to determine the nature and severity of any neurological problems associated with the service-connected low back strain with collapsed disc space. In addition to nerve conduction studies and an electromyogram, any other additional testing deemed necessary should be performed. The claims folder should be made available to the examiner in conjunction with the examination. Thereafter, the case should be reviewed by the RO. If the benefits sought on appeal is not granted, the appellant and his representative should be furnished a supplemental statement of the case and an opportunity to respond. The case should be returned to the Board for further appellate consideration. J.F. GOUGH 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) (1994).