Citation Nr: 0002316 Decision Date: 01/28/00 Archive Date: 02/02/00 DOCKET NO. 95-01 198 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a lumbar spine disorder, secondary to service-connected pilonidal cystectomies. 2. Entitlement to an evaluation in excess of 10 percent for the residuals of pilonidal cystectomies with tender scar. 3. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities. REPRESENTATION Appellant represented by: Richard A. La Pointe, Attorney ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The veteran had active service from February 1954 to February 1956. This matter comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Waco, Texas, regional office (RO) of the Department of Veterans Affairs (VA). It was previously before the Board in August 1996, but was remanded for additional development. The requested development has been completed, and the case has been returned to the Board for further review. In August 1999, the Board requested an additional medical opinion from a VA physician. This opinion was received in September 1999. The veteran and his representative were provided with a copy of this opinion and notified that they would have 60 days in which to submit additional evidence or argument in October 1999. This 60 day period ended without the receipt of additional evidence or argument. FINDINGS OF FACT 1. The veteran's degenerative joint disease of the lumbar spine was not caused or aggravated by the service connected residuals of a pilonidal cyst. 2. The veteran's surgical scar is no more than tender and painful; the scar is not ulcerative and does not result in limitation of function of the lower back. There has not been a recent recurrence of a pilonidal cyst. 3. The veteran's only service-connected disability consists of residuals of pilonidal cystectomies with tender scar, now evaluated as 10 percent disabling. 4. The veteran's service-connected disability does not create an exceptional or unusual disability picture resulting in his unemployability. CONCLUSIONS OF LAW 1. The veteran's degenerative joint disease of the lumbar spine is not proximately due to or the result of his service connected residuals of pilonidal cystectomy. 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 3.310(a) (1999). 2. The criteria for an evaluation in excess of 10 percent for the residuals of pilonidal cystectomies with tender scar have not been met. 38 U.S.C.A. § 1155, 5107 (West 1991); 38 C.F.R. § 4.118, Codes 7803, 7804, 7805 (1999). 3. The criteria for a total rating based on individual unemployability due to service connected disabilities have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.15, 4.16 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran contends that his service connected tender scar as a residual of pilonidal cystectomies is productive of a much greater level of severity than is reflected by the 10 percent evaluation currently in effect. He argues that his disability is productive of a great degree of pain, which impairs his ability to be employed. He further contends that he has developed a lumbar spine disability secondary to his service connected tender scar. Finally, the veteran contends that his disabilities cause a high degree of functional impairment of the low back, and combine to render him unemployable. Factual Background A review of the service medical records indicates that the veteran underwent incision and drainage of a pilonidal sinus with abscess in January 1956. The February 1956 discharge examination noted that the veteran had recently undergone this procedure. This examination was negative for a back disability. VA hospital records show that the veteran was admitted for treatment of his pilonidal cyst and sinus in March 1956. He underwent surgery for removal of the pilonidal cyst and sinus. There was no evidence of treatment of a disability of the lumbar spine. Entitlement to service connection for the residuals of a pilonidal cystectomy was established in a January 1967 rating decision. A 10 percent evaluation was established for this disability under the provisions of 38 C.F.R. § 4.118, Code 7804, the rating code for scars that are superficial, tender, and painful on objective demonstration. This evaluation currently remains in effect. The veteran underwent a VA examination in July 1982. He indicated that he had back lesions from basic training, and that he was unable to drive, stand, or sit for very long. He would lay down until his pain ended. After examination, the diagnosis was residuals of pilonidal cystectomy with subjective evidence of tenderness of the scar. A September 1982 letter from a private doctor states that he had examined the veteran for his back complaints, which he alleged were the result of lacerations to his back when he was cut by barbed wire during his basic training. The impression was acne scars of the back. An October 1982 letter from a private doctor states that part of the veteran's pain in his back was the result of the scar tissue from the surgery performed on his pilonidal sinus. However, a review of the veteran's X-rays revealed some arthritic changes that led him to believe that most of these findings were a direct result of the long-standing inflammatory process caused by the active pilonidal sinus. The veteran underwent a VA examination by an orthopedic consultant in February 1983. The opinion by the October 1982 private physician was noted. The diagnoses of this examination included tender scar with low back pain, pilonidal cyst history with multiple operations, acne vulgaris, and low back pain with degenerative changes in the lumbar spine, arthritic, symptomatic, associated with the pilonidal cyst history. The report of a July 1990 private medical examination conducted by M. P., M.D., an orthopedic surgeon, noted the veteran's history of treatment for an infected pilonidal cyst. The veteran's work history noted that he had a high school education, and had attended community college. He had training in real estate and insurance sales. The veteran indicated that he was the owner of a real estate and insurance company, and had owned this company for the past 40 years. He had not worked since approximately June 1990 due to his pain. His duties at work consisted of selling insurance and running his business. He did not have any other employees, and had to close his office when he was in pain. His duties consisted of walking, standing, doing paperwork, prolonged sitting, and driving. Any sitting, walking, or standing would aggravate his condition. He did not feel able to continue working because of his pain. Following the examination, the diagnosis was a persistent post-traumatic chronic lumbar spondyogenic (ruptured disc) discogenic pain syndrome, with residual chronic pilonidal cyst pain syndrome. The report of a September 1991 private examination conducted by D. A., M.D. states that the veteran's problems began when he developed a pilonidal cyst in service which necessitated multiple operations. He had subsequently developed chronic pain, which had progressed. The veteran currently had continuous low back pain with radiation to the buttocks but not the legs. The impressions were chronic severe low back pain without evidence of radiculopathy, multilevel lumbar degenerative disc disease, and chronic pain secondary to multiple surgeries for pilonidal cyst. Surgery was not required, but the veteran was to be managed with reduced activities, medication, and above all else, weight loss. He was unable to do prolonged sitting, walking, or standing, and was not to lift anything heavier than five pounds. A copy of a December 1992 Social Security decision is contained in the claims folder. This decision indicates that the veteran was considered disabled from August 1989. His disabilities were a pilonidal cyst, and multi-level degenerative disc disease. In a January 1993 letter, P. M., M.D., says that he has treated the veteran since 1990. The veteran's back condition was unimproved. The diagnosis was persistent post-traumatic chronic lumbar spondylogenic (anular tear) discogenic pain syndrome. A March 1993 letter from this same physician says that the veteran has not improved, and that he carried a diagnosis of persistent post-traumatic chronic lumbar spondylogenic (anular tear) discogenic pain syndrome secondary to multiple pilonidal cystectomies. He noted that this diagnosis was supported by the September 1991 examination report from another private doctor. The veteran was afforded a VA examination in April 1993. The history of the treatment for the pilonidal cyst in service was noted. The veteran also reported a history of a low back injury during service. He stated that a sergeant stepped on his back as he was crawling on the ground during military exercises in basic training. He was not allowed to receive medical treatment for this injury. The veteran reported low back pain since that time. The veteran also reported that private doctors had diagnosed post-traumatic chronic lumbar spondylogenic ruptured disc, pain syndrome, and chronic pilonidal cyst pain syndrome. On examination, there was a large scar noted in the coccyx area at the site of the old pilonidal cyst and subsequent multiple cystectomies. The surgical scar was definitely tender to palpation. There were no cysts noted at the present time, no infection, and no abscess. The doctor's remarks said that the chronic low back pain was due to the degenerative osteoarthritis and degenerative disc disease of the lumbar spine. The veteran also had chronic scar tissue pain as a residual of multiple pilonidal cystectomies. In his opinion, it was possible that the chronic low back pain aggravated the scar tissue pain. The diagnoses included pilonidal cysts, recurrent, not found at present, status post pilonidal cystectomies time three, degenerative osteoarthritis of the lumbar spine with degenerative disc disease, particularly noted at L1 to L2, and L5 to S1. An April 1993 letter from D. A., M.D., says that the veteran was essentially unchanged since the September 1991 examination. The impressions were chronic, severe, low back pain without evidence of radiculopathy, multilevel lumbar degenerative disc disease, and chronic pain secondary to multiple surgeries for pilonidal cyst. A letter from J. N., M.D., notes that he examined the veteran in April 1993. He indicated that the veteran had a history of pain at the site of his old surgery for the pilonidal cyst. This pain was aggravated by chronic low back pain. On examination, the veteran had a scar at the midline of the gluteal cleft consistent with previous pilonidal surgeries, which was still tender on examination. There was no evidence of infection or abscess, but there was evidence of chronic scar tissue. He believed that the veteran had chronic pain secondary to multiple surgeries at the site of the pilonidal disease, which might be resulting from the chronic scar tissue. In November 1993, the veteran submitted the answers of M. P., M.D., to a set of interrogatories. The answers of P. M., M.D., to the same interrogatories were also submitted at this time. They both agreed that they had examined the veteran for his pilonidal cystectomy and his lumbar spondylogenic discogenic pain syndrome and related back problems. They checked yes when asked whether the veteran's back problems and resulting pain were the result of his original pilonidal cyst surgeries, and that his impairment would remain the same or worse. The veteran had pain as a result of his cyst and back problems. They both said that the pain was continuous. M.P. said that the scarring from the multiple surgeries for the pilonidal cyst caused the pain. P.M. stated that the pain was caused by sitting, bending, and standing. They both believed that the veteran was totally disabled from working due to his pilonidal cyst and back problems, and that he was precluded from performing a job that required prolonged standing or sitting. M.P. noted that prolonged sitting would aggravate the veteran's disability. An X-ray study of the veteran's spine was conducted in November 1998 and revealed generalized osteopathy, lumbar scoliosis and spondylosis, osteoarthritis of L3 to L4, L4 to L5, and L5 to S1, and spondylosis of L4 to L5, and L3 to L5. The veteran was afforded a VA fee basis examination by an orthopedist in December 1998. He was noted to have undergone three operations between 1954 and 1956 for pilonidal cysts. He had trouble with healing and apparently had defective scar formation that caused low back pain. The pain did not radiate to the lower extremities, but it apparently disabled him progressively until he retired in 1992. The pain was constant, was located in the lumbosacral and coxis area, and occasionally went upwards to the lumbosacral and lumbar area. It had never radiated to the lower extremities. The veteran complained that he could not tolerate walking and prolonged sitting. He treated the pain with hot baths, and occasional Tylenol. He did not do anything, drove only occasionally, could walk for 15 minutes, and stand or sit for only 10 minutes. On examination, the veteran dressed and undressed complaining of extreme pain. He was obese and walked slowly. Tip toes and heel walking were performed complaining of severe pain. The diagnoses included status post multiple surgical procedures for pilonidal cysts with apparently very sensitive scar formation at the intergluteal area, and severe osteoarthritis of lumbosacral spine. The doctor stated that he did not believe the osteoarthritis of the spine had any relationship with the pilonidal cyst operations. A January 1999 fee basis examination states that from the point of view of a dermatologist, the veteran's scars were normal, and could hardly be considered to cause the problems complained of by the veteran. The scars were soft without hypertrophy, and they moved easily over subjacent tissues. The examiner found that the scars were normal and not the cause of the present illness, which should be treated from the point of view that it was osteoarthritis. A medical opinion from a VA orthopedic surgeon was obtained in September 1999. The doctor noted that he had reviewed the veteran's service medical records, as well as the VA and private medical records before rendering his opinion. The history of treatment with incision and drainage on two occasions in service for an abscessed pilonidal cyst was noted, as was the pilonidal cystectomy conducted by the VA shortly after discharge. The doctor noted that the veteran did not complain of any back injury, problem, or pain during service, and that the first indication of a complaint for back pain was dated July 1982, 26 years after discharge. The veteran had been evaluated for his complaints of chronic pain associated with the scarring from the pilonidal cyst surgery, as well as gradually increasing back pain on several occasions by several different doctors. The diagnoses were noted to include discogenic pain in addition to degenerative arthritis of the lumbar spine, although there had never been any report of a neurological deficit or a radicular component to the veteran's pain. The doctor stated that it was his opinion that the degenerative joint disease of the lumbar spine was in no way connected to the veteran's pilonidal cyst and subsequent abscess formation. It was also his opinion that the degenerative arthritis of the lumbar spine which had developed through the years as a result of normal wear and tear had not been aggravated or affected in any way by the pilonidal cyst problem. Service connection for Lumbar Spine Disorder Initially, the Board notes that although the veteran made an unsubstantiated claim of an injury to his back during basic training, he has confined his contentions in his appeal to the claim that his lumbar spine disorder has developed secondary to his service connected disability. Therefore, the Board will confine its analysis to service connection as secondary to the veteran's service connected disability. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service connected disability. In this instance, the veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). A person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. 38 U.S.C.A. § 5107. A well grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. The claim does not need to be conclusive, but only possible in order to be well grounded. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The appellant has the burden of submitting evidence to show that the claim is plausible. Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). In a claim for secondary service connection for a diagnosis clearly separate from the service-connected disorder, the veteran must present evidence of a medical nature to support the alleged causal relationship between the service-connected disorder and the disorder for which secondary service connection is sought, in order for the claim to be well- grounded. See Jones v. Brown, 7 Vet. App. 134 (1994). The Board finds that the veteran has submitted evidence of a well grounded claim for entitlement to service connection for a lumbar spine disorder, secondary to service-connected pilonidal cystectomies. The evidence contains several medical opinions which state that the veteran has developed arthritis of the lumbar spine as a result of his pilonidal cysts. After careful review of the veteran's contentions and the evidence of record, the Board is unable to find that entitlement to service connection for a lumbar spine disorder is warranted. The evidence includes several opinions concerning the veteran's claim, some of which agree with his contentions, and some of which do not. However, the Board finds the September 1999 medical opinion from the VA orthopedic surgeon to be the most probative opinion, and this opinion states that the degenerative joint disease is in no way connected to the veteran's pilonidal cyst. The doctor who provided the September 1999 opinion is an orthopedic surgeon. There is no indication that the private doctor who rendered the October 1982 opinion has any special training or experience in orthopedics. Similarly, J. N., the doctor who wrote an April 1993 letter, is not an orthopedist, and P. M., who has submitted several opinions in favor of the veteran's claim, is a specialist in emergency medicine. The Board finds that a specialist in the field of orthopedics would likely have more expertise in the etiology of orthopedic diseases than doctors who are not board certified in this area. The Board notes that the February 1983 VA examination was conducted by an "orthopedic consultant". The report did not explicitly state that the veteran's degenerative changes of the spine developed secondary to this pilonidal cyst. Rather, it states that the veteran has low back pain with degenerative changes in the lumbar spine that are "associated" with the pilonidal cyst history. This physician cited to an earlier private medical report and did not clarify whether the purported association was etiological or merely that the pain from each emanated from the same anatomical area. The Board finds that the September 1999 opinion is the stronger opinion because it is written by an orthopedic surgeon and does reach an explicit opinion concerning the possibility of a relationship between the veteran's degenerative joint disease of the lumbar spine, and it states that degenerative joint disease of the lumbar spine is in no way connected to the veteran's pilonidal cyst and subsequent abscess formation. Finally, the Board recognizes that M.P., M.D., is also an orthopedic surgeon, and he has rendered opinions in favor of the veteran's claim. However, the Board notes that the July 1990 letter from M. P., which was the first that was submitted, did not opine that the veteran's arthritis has resulted from or was aggravated by the veteran's pilonidal cyst. The November 1993 interrogatories do state that the veteran's "back problems and resulting pain stem from his original pilonidal cyst surgeries". However, the Board notes that this answer was worded by the veteran's representative, and not M. P., who merely had the option of checking yes or no to this statement. M.P. did not explain the reasoning behind his conclusions and there is no evidence to indicate that M.P. ever examined the veteran's complete medical records before rendering his opinion. The September 1999 VA orthopedic surgeon was able to review the entire file before reaching his opinion. This included the service medical records and VA records pertaining to the treatment of the cyst when it was active and infected. The September 1999 examiner was able to base his opinion on a medical picture of the veteran that was more accurate and complete. As the September 1999 medical opinion is clearly the most probative opinion of record, and as this opinion indicates that the veteran's degenerative joint disease neither developed due to the pilonidal cyst nor was aggravated by the cyst, the preponderance of the evidence is against the veteran's claim for service connection for a lumbar spine disorder. Evaluation of Tender Scar Initially, the Board finds that the veteran's claim for an increased evaluation is "well-grounded" within the meaning of 38 U.S.C.A. § 5107(a); that is, a plausible claim has been presented. Murphy v. Derwinski, 1 Vet. App. 78 (1990). An allegation of increased disability is sufficient to establish a well-grounded claim seeking an increased rating. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). The Board is also satisfied that all relevant facts have been properly developed to their full extent and that the VA has met its duty to assist. White v. Derwinski, 1 Vet. App. 519 (1991); Godwin v. Derwinski, 1 Vet. App. 419 (1991). The evaluation of service-connected disabilities is based on the average impairment of earning capacity they produce, as determined by considering current symptomatology in the light of appropriate rating criteria. 38 U.S.C.A. § 1155. Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In addition, the entire history of the veteran's disability is also considered. Consideration must be given to the ability of the veteran to function under the ordinary conditions of daily life. 38 C.F.R. § 4.10. If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. 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. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). The veteran's tender scar as a residual of pilonidal cystectomies is evaluated under the rating code for scars that are superficial, tender, and painful on objective demonstration. This warrants a 10 percent evaluation. 38 C.F.R. § 4.118, Code 7804. Scars that are superficial and tender may also merit a 10 percent evaluation. 38 C.F.R. § 4.118, Code 7803. The Board finds that entitlement to an evaluation in excess of 10 percent for the veteran's tender scar as a residual of his pilonidal cystectomy is not warranted. The April 1993 letter states that the veteran's scar was still tender. Furthermore, the December 1998 VA fee basis orthopedic examination notes that the veteran apparently has tenderness in the area of his scar. However, the January 1999 fee basis dermatology examination found that the veteran's scars were normal. They were soft, without hypertrophy, and moved easily over subjacent areas. Moreover, the veteran is already in receipt of a 10 percent evaluation for his scar, which is the highest evaluation allowed in the rating code for this disability. 38 C.F.R. § 4.118, Codes 7803, 7804. The Board has also considered an evaluation of the veteran's disability under the provisions of 38 C.F.R. § 4.118, Code 7805 for other scars. However, the limitation of function of the veteran's lower back is the result of the nonservice connected lumbar spine disability instead of his scar, and the January 1999 fee basis examination specifically attributes the veteran's impairment to the osteoarthritis. The application of 38 C.F.R. § 3.321 will be discussed below in the context of the veteran's claim for a total rating based on unemployability. Therefore, entitlement to an evaluation in excess of 10 percent is not merited. Total Rating due to Individual Unemployability The VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience by reason of his service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16. If the appropriate rating under the pertinent diagnostic code of the rating schedule is less than 100 percent, the issue of unemployability must be determined without regard to the advancing age of the veteran. 38 C.F.R. §§ 3.341(a), 4.19. Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). According to the applicable laws and regulations, a total rating for compensation may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. Part 3, §§ 3.340, 4.16(a). However, a total rating based on individual unemployability may still be assigned to a veteran who fails to meet these percentage standards if he or she is unemployable by reason of his or her service-connected disability(ies). 38 C.F.R. § 4.16(b). In determining whether the veteran is entitled to a total disability rating based upon individual unemployability, neither his non-service-connected disabilities nor his advancing age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993); 38 C.F.R. § 3.341(a). In Hatlestad v. Derwinski, 1 Vet.App 164 (1991), the United States Court of Veterans Appeals (Court) referred to apparent conflicts in the regulations pertaining to individual unemployability benefits. Specifically, the Court indicated there was a need for discussing whether the standard delineated in the controlling regulations was an "objective" one based on average industrial impairment or a "subjective" one based upon the veteran's actual industrial impairment. The Board is bound in its decisions by the regulations, the Secretary's instructions and the precedent opinions of the chief legal officer of VA. 38 U.S.C.A. § 7104(c) (West 1991). In a pertinent precedent decision, the VA General Counsel concluded that the controlling VA regulations generally provide that veterans who, in light of their individual circumstances, but without regard to age, are unable to secure and follow a substantially gainful occupation as a result of service-connected disability shall be rated totally disabled, without regard to whether an average person would be rendered unemployable by the circumstances. Thus, the criteria include a subjective standard. It was also determined that "unemployability" is synonymous with inability to secure and follow a substantially gainful occupation. VA O.G.C. Prec. Op. No. 75-91 (Dec. 27, 1991). For a veteran to prevail on a claim based on individual unemployability, it is necessary that the record reflect some factor which takes the claimant's case outside the norm of such a veteran. See 38 C.F.R. §§ 4.1, 4.15 (1998). The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. See 38 C.F.R. 4.16(a); Van Hoose, 4 Vet. App. at 363. If total industrial impairment has not been shown, the VA is not obligated to show that a veteran is incapable of performing specific jobs in considering a claim for a total rating based on individual unemployability. See Gary v. Brown, 7 Vet. App. 229 (1994). In this case, the veteran's only service connected disability is the tender scar as a residual of the pilonidal cystectomy. As discussed above, a 10 percent evaluation is the proper rating for this disability. Therefore, as the veteran has not met the percentage requirements set forth in 38 C.F.R. § 4.16(a), the Board will proceed with consideration of entitlement to an extraschedular evaluation under the provisions of 38 C.F.R. § 4.16(b). The evidence shows that the veteran was formerly self- employed in the real estate and insurance business. The September 1991 examination noted that prolonged sitting, walking, or standing, and lifting more than five pounds was precluded by his back disability and the pain from his surgeries. The December 1992 Social Security decision found that the veteran was disabled due to the cyst and the back disability. The November 1993 interrogatories both state that the veteran is totally disabled due to his back disability and his pilonidal cyst, and that he is precluded from a job that requires prolonged standing or sitting. However, none of this evidence indicates that the veteran is rendered unemployable solely due to his service connected disability. Rather, the evidence strongly suggests that the veteran's primary disability is his nonservice connected degenerative joint disease of the lumbar spine. The examination that best differentiates between the impairment that results from the back disability and the disability as a result of the scar is the January 1999 fee basis examination by the dermatologist, and this examiner indicates that the veteran's impairment is the result of the osteoarthritis, and not the scar. There is no indication that his service connected scar requires frequent hospitalization, and there is no other evidence to demonstrate an exceptional or unusual disability picture that would preclude a veteran with his education and work experience from obtaining anything but marginal employment as the result of his scar. Therefore, as the evidence does not show that the veteran's service connected disability prevents him from obtaining employment, a total rating is not merited. ORDER Entitlement to service connection for a lumbar spine disorder, secondary to service-connected pilonidal cystectomies, is denied. Entitlement to an evaluation in excess of 10 percent for the residuals of pilonidal cystectomies with tender scar is denied. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities is denied. THOMAS J. DANNAHER Member, Board of Veterans' Appeals