Citation Nr: 0002484 Decision Date: 02/01/00 Archive Date: 02/10/00 DOCKET NO. 96-34 083 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to an increased evaluation for arthritis of the lumbar spine with radiculopathy and limitation of motion due to shrapnel wounds, currently rated 60 percent disabling. 2. Entitlement to an increased evaluation for arthritis of the cervical spine with limitation of motion due to shrapnel wounds, currently rated 30 percent disabling. 3. Entitlement to an increased evaluation for shrapnel wounds to the abdomen, currently rated 30 percent disabling. 4. Entitlement to an increased evaluation for shrapnel wounds of the right forearm, currently rated 30 percent disabling. 5. Entitlement to an increased evaluation for shrapnel wounds of the chest, currently rated 10 percent disabling. 6. Entitlement to an increased evaluation for shrapnel wound of the right thigh, currently rated 10 percent disabling. 7. Entitlement to an increased evaluation for wound scars of the face and neck, currently rated 10 percent disabling. 8. Entitlement to an increased evaluation for shrapnel wound of the left knee, currently rated 10 percent disabling. 9. Entitlement to an increased (compensable) evaluation for scars of the abdomen, trunk and chest. 10. Entitlement to an increased (compensable) evaluation for scars of both upper and lower extremities. REPRESENTATION Appellant represented by: Connecticut Department of Veterans Affairs WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD R. E. Smith, Counsel INTRODUCTION The veteran had active military service from September 1968 to February 1971. This matter came before the Board of Veterans' Appeals (Board) on appeal from an April 1996 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut, which denied the veteran increased evaluations for his service-connected disabilities in issue. A subsequent rating action by the RO in August 1997, continued the earlier denial of an increased evaluation for the veteran's service-connected disabilities exclusive of the veteran's service-connected shrapnel wound residuals of the right forearm. The rating for this disorder was increased from 10 percent to 30 percent, effective from February 1995. In May 1999, the veteran appeared and offered testimony before the undersigned member of the Board at the RO. Testimony elicited at this hearing included the veteran's disagreement with an RO rating action in March 1999, which denied him entitlement to individual unemployability from August 8, 1995. This issue will be further addressed in the remand section below. A transcript of the veteran's hearing testimony on this occasion has been associated with his claims file. FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the RO. 2. The veteran's lumbar spine disorder is currently evaluated at the maximum rating for intervertebral disc syndrome and is not shown to be manifested by residuals of a fracture of the vertebra or ankylosis. 3. Arthritis of the cervical spine is currently manifested by no more than severe functional impairment. 4. The service-connected abdominal shrapnel wounds are manifested by partial obstruction shown on upper gastrointestinal series in an area punctured in the original injury, with episodes of nausea and vomiting, following surgery with drainage; the symptoms more closely approximate a severe disability. 5. The veteran's shrapnel wound of the right forearm is productive of no more than severe incomplete paralysis of the ulnar nerve. 6. Residuals of shrapnel wounds of the chest represent no more than moderate muscle injury without impairment to respiration. 7. The veteran's shrapnel wound of the right thigh is manifested by diminished sensation only. 8. Shell fragment wounds of the scars on the face and neck are well healed, non-tender, and produced no more than moderate disfigurement. 9. Residuals of a shell fragment wound of the left knee are manifested by discomfort compatible with no more than painful and tender scarring 10. Scars of the abdomen, trunk, and chest are well healed, non-tender, with no evidence of interference or impairment of function. 11. Scars of the upper and lower extremity are well healed, non-tender, with no evidence of interference or impairment of function. CONCLUSIONS OF LAW 1. The schedular criteria for an increased evaluation in excess of 60 percent for arthritis of the lumbar spine with radiculopathy and limitation of motion due to shrapnel wounds have not been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.10 and Part 4, Code 5010-5293 (1999). 2. The schedular criteria for an increased evaluation in excess of 30 percent for arthritis of the cervical spine with limitation of motion due to shrapnel wounds have not been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.40, 4.45, 4.59 and Part 4, Code 5010-5290 (1999). 3. The schedular criteria for a 50 percent evaluation for shrapnel wounds of the abdomen have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10 and Part 4, Code 7301 (1999). 4. The schedular criteria for an increased evaluation in excess of 30 percent for a shrapnel wound of the right forearm have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.20 and Part 4, Code 8516 (1999). 5. The schedular criteria for an increased evaluation in excess of 10 percent for shrapnel wounds of the chest have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7, and Part 4, Code 5321 (1999). 6. The schedular criteria for an increased evaluation in excess of 10 percent for residuals of a shrapnel wound of the right thigh have not been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.10, and Part 4, Code 8520 (1999). 7. The schedular criteria for an increased evaluation in excess of 10 percent for wound scars of the face and neck have not been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7 and Part 4, Code 7800 (1999). 8. The schedular criteria for an increased evaluation in excess of 10 percent for residuals of a shrapnel wound of the left knee have not been met. 38 U.S.C.A. §§ 1155, 5107(a) (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.7 and Part 4, Code 7804. 9. The schedular criteria for a compensable rating for scars of the abdomen, trunk and chest have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7 and Part 4, Codes 7804, 7805 (1999). 10. The schedular criteria for a compensable evaluation for scars of both upper and lower extremities have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, and Part 4, Codes 7804, 7805 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran has submitted well-grounded claims within the meaning of 38 U.S.C.A. § 5107(a) and VA has properly assisted him with the development of his claim. No further assistance to the veteran is thus required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). All relevant facts have been properly developed and all evidence necessary for an equitable resolution of the issues on appeal has been properly obtained by the RO. The evidence includes the veteran's service medical records, records of treatment following service and reports of VA rating examinations. The Board is not aware of any additional relevant evidence, which is available in connection with this appeal. I. Summary of Facts The veteran's service medical records show that in May 1969 while on patrol in Vietnam the veteran sustained multiple shrapnel wounds from a hostile mortar round. He was evacuated to the Naval Support Activity Hospital in Danang, Vietnam, where examination revealed multiple shrapnel wounds of the face, chest, abdomen, both lower extremities, and lateral walls of the right maxillary sinus with multiple fragments within the soft tissues of the face. Abdominal X- rays revealed three intra-abdominal fragments and multiple fragment wounds of the lower extremities without fractures. X-ray of the chest revealed a lung contusion involving the right upper lobe. Under general anesthesia all wounds were debrided and an exploration of the right maxillary sinus was carried out. An arthrotomy was performed on the left knee resulting in a finding of a small fracture to the inferior pole of the left patella. An exploratory laparotomy was also performed. There was a 3- millimeter to 4-millimeter puncture wound of the dome of the right lobe of the liver, a through-and-through perforation of the second portion of the duodenum, and a perforation of the transverse colon. The through-and-through perforation of the duodenum was closed primarily and a transverse end colostomy was performed with distal mucous fistula. Following several closed thoracostomies and a tracheostomy the veteran was noted to improve. In late May 1969 all drains were removed and all wounds of the chest, abdomen and thigh were revised and closed. The veteran was evacuated to the continental United States for further evaluation and treatment at the U.S. Naval Hospital in Newport, Rhode Island, where an admission examination revealed the presence of several well-healed facial wounds, tenderness over the right maxillary sinus, and a healed tracheostomy scar on neck examination. An examination of the chest at this time revealed a slightly draining shrapnel wound of the right anterior thorax. Examination of the abdomen revealed the presence of a functioning transverse colostomy with distal mucous fistula. Otherwise the abdomen was soft and non-tender to palpation with numerous healing soft tissue wounds. Examination of the extremities revealed multiple healing soft tissue wounds. Examination of the right arm revealed a positive Tinel sign over the ulnar nerve at the elbow at the site of a shrapnel wound. Examination of the left knee revealed full range of motion with some discomfort and slight quadriceps atrophy. The remainder of the physical examination was essentially unremarkable. While hospitalized, the veteran continued to improve with satisfactory healing of all soft tissue wounds. The colostomy continued to function normally. In mid-July 1969 a revision and closure of the transverse colostomy was performed. The veteran did experience some spontaneous drainage from his midline surgical wound as a result of some necrosis in the subcutaneous tissue with a small portion of the wound infection extending through the fascia with a small fascial separation. This drainage was treated with dressing changes and soaks. In December 1969 the veteran had progressed to where he was felt to be fit for limited duty. On his initial VA examination in May 1971 the veteran complained of adhesions, nasal discomfort and facial pains. The veteran said that the scars in his abdomen were all tender and that he has a feeling of constant constipation after eating and can eat only small multiple feedings per day. He complained of pain before evacuation of his bowels often of a severe and debilitation nature as well as cramps. Examination of the head, face and neck was normal other than for a right cheek scar and scattered scars, described as tracheostomy and mid-chin. The veteran was also noted to have multiple abdominal scars including midline 15-inch xiphoid to pubis scar with puckering and contracture in its midportion at the site of excision of a chronically draining sinus tract. There was generalized tenderness present over the abdominal scar as well as the abdomen and over a suprapubic scar where a catheter had been placed in his bladder. Further scarring consisted of a 1 1/4-inch linear upper left anterior chest surgical scar three inches long on the right axilla, 1 1/2-inch scar on the left axilla, scars on the upper and lower forearms bilaterally with the one on the left anterior forearm showing muscular herniation through it. There were scars in the calf posteriorly, burn scars on the right neck and calf and anteriorly placed thigh scars in addition to the surgical scar about the medial left knee for a fracture of the left patella and arthrotomy. While all these were present and more, there was little functional effect noted in muscular range of motion. On special orthopedic examination, the veteran was described as a well-developed, well-muscled individual. Examination of the upper extremities revealed a normal shoulder girdle and normal left upper extremity. There were several scars of note on the right upper extremity with a 2-centimeter scar over the mid-bicep mass of the anterior right arm, non-tender and with no palpable defect beneath it. There was an oblique 2- by 6-centimeter scar over the mid-flexor mass in the right forearm. There was a 2- by 2-centimeter palpable fascial defect in the midportion of the scar with herniation of muscle through this fascial defect on forearm flexion. There was no deficit of motor or sensory function in the right upper extremity. There were multiple small scars of both lower extremities. There was an entirely normal range of motion of both hips, both knees, and all distal lower extremity joints in both legs. There was mild left calf and thigh atrophy. There was normal sensation in both lower extremities except for a widespread hypesthesia, which covered most of the anterior left thigh below the level of the junction of the middle and proximal thirds of the femur. Specific examination of the left knee revealed no ligamentous laxity. X-rays were interpreted to reveal shrapnel in the chest and left knee with normal chest and scalp. A barium enema was essentially negative. The VA examiner commented that although the veteran has multiple scars and objective evidence of many relatively minor findings, he did not believe that the veteran's functional loss was of great consequence. By an October 1971 RO rating action service connection was established for shrapnel wound scars of the face and neck, rated 10 percent disabling; residuals of shrapnel wound to the right forearm, right thigh, left knee, abdomen and chest each of which were rated 10 percent disabling, and scars of both upper and lower extremities, and scars of the abdomen, trunk and chest, each rated noncompensably disabling. In September 1978 the veteran was hospitalized at a VA medical center for severe right groin pain. A right inguinal exploration was undertaken and a finding of a neuroma involving the right ileal inguinal nerve was made. The neuroma was resected and the incision closed. An RO rating action in December 1978 increased the disability evaluation for the veteran's service-connected residuals of shrapnel wounds of the abdomen from 10 percent to 30 percent disabling, effective from August 1978. Private clinical records from Lawrence and Memorial Hospital, received in connection with the veteran's current claim, revealed hospitalization and treatment provided to the veteran from December 1972 to February 1995 for various conditions to include a puncture wound of the right hand, chronic pancreatitis, hemoptysis of unknown etiology and a perforated appendicitis. In November 1993 the veteran was admitted with a cervical radiculopathy related to a C5-6 disc herniation on the right without any recollection of a specific injury that might have precipitated the problem. The veteran underwent an anterior cervical diskectomy and autogenous iliac crest graft fusion at C5/6. In February 1995 he presented with back pain with some radiation down the left leg with feelings of dysesthesia and tingling in the left foot but also the right. It was the diagnostic impression that the veteran had an atypical pain problem. The veteran was provided a lumbar epidural steroid injection. An evaluation of the veteran's low back and lower extremity pain was made by Dr. Philo F. Willetts, Jr., in February 1995. At that time the veteran was noted to have sustained an on-the-job injury in February 1994 to his right buttock and right side due to a slip and fall accident. The veteran reported that he last worked in December 1994. On physical examination the veteran was noted to have multiple areas of shrapnel wounds including wounds on the thighs, knees, and abdomen. Inspection of the back was normal. Range of motion of the back was indicated to be normal in all planes. Toe and heel walking was normal without weakness. Straight leg raising was mildly painful at 90 degrees bilaterally while seated. While supine, the veteran reported pain at 70 degrees on the left and 90 degrees on the right. Motor examination showed normal and equal muscle strength over all muscle groups of both lower extremities. Pinprick sensation showed decreased reported sensation over the anterior proximal right thigh. Abdominal examination revealed multiple scarring and mild tenderness. X-rays revealed some mild degenerative changes over the mid and lower thoracic vertebral bodies as well as significant degeneration of the sacroiliac joints. On VA examination in June 1995 the veteran complained of headaches, difficulty with use of his right arm, problems with painful sexual intercourse and vague tenderness and nausea in the epigastric area. On examination the veteran was noted to have numerous well-healed shrapnel wound scars all over his body and on his extremities. The abdomen was soft with tenderness in the epigastric and right upper quadrant areas on slight touching. Range of motion of the musculoskeletal system was grossly normal without restrictions. The left patellar area was tender with crepitation. Right hand grip was slightly decreased. On nervous system examination the sensory and motor system were normal. There was some right forearm impairment of coordination. The veteran was provided a neurological evaluation by a private physician, Stanley G. Puggley, M.D., in September 1995 for complaints of diffuse, apparently joint-related pain of a progressive nature. He stated that his main pain involved intense aching discomfort in his neck and low back. The veteran also complained that his hip and knees also felt very stiff and achy. On physical examination, the veteran demonstrated diffuse discomfort on range of motion of all joints but particularly in the neck and in the knees. There was no obvious joint deformity. There were no skin lesions beyond his preexisting scars from his shrapnel injury. Motor examination was normal although some giveaway discomfort was noted proximal to the arms because of neck discomfort. Sensory examination was normal to pinprick and to light touch. Reflexes were one plus in all extremities. The examiner concluded as a diagnostic impression that the veteran's complaints of pain appeared clinically to have more of an arthritic than neurogenic basis. Dr. Willetts conducted a reexamination of the veteran in September 1995. The veteran further elaborated on his on- the-job back injury in February 1994 and subsequent problems with back discomfort. The veteran said that sitting, writing, twisting in a chair and getting up and down all hurt. On physical examination some spasm was noted over the lumbar spine. Spinal motion was decreased at 28 degrees' flexion, 18 degrees' extension. Straight leg raising was uncomfortable at 80 degrees. Motor examination showed normal and equal muscle strength over all muscle groups of both lower extremities. Sensation to pinprick was highly variable without consistent deficits. Abdominal examination showed tenderness over the lower quadrant related to the veteran's war wounds. At a personal hearing on appeal in August 1996 the veteran testified that contact of any type with his stomach caused him discomfort, including nausea and occasional vomiting. The veteran indicated that his stomach was his biggest problem and that he currently had an abscess from his wounds. He said that he had problems with digestion to include constipation and diarrhea. The veteran stated that he had problems with lifting and walking up stairs. The veteran said that he experiences increased pain in his right arm radiating downward from the elbow to the fingers as well as a lack of strength. He further said that he had difficulty clenching his fist and holding objects such as a phone, for any prolonged period. The veteran also said that he had pain in his shoulder as a result of a herniated disc in his neck. With respect to his scarring the veteran stated that "the most that's caused me the problem are in the belly and all." He said the scars on his face and neck are more visible now than before and are causing a drooping effect to his cheek and lip. He further described difficulties with his left knee, sinuses, migraine headache, and jaw. Private outpatient treatment records from Dr. Thomas Kuchirchik and compiled between July 1995 and September 1996 show evaluation and treatment provided to the veteran for complaints of back and abdominal pain. The veteran was noted to have a stitch abscess in the area of his abdominal incision in May 1996 and was treated for related drainage. On VA examination in January 1997 the veteran related a history of multiple shrapnel wounds from a 60-millimeter mortar shell. His most serious wounds were noted to be to the abdomen but he also was noted to have had injuries to both lower and both upper extremities as well as the face and neck. The veteran was also noted to have a work-related injury to his lower back in 1994 and a history of anterior cervical diskectomy that same year. On physical examination the veteran was noted to walk very slowly in a flexed position at 35 degrees in the lumbar spine. His leg lengths were equal. He could not walk on his heels and toes. He had tenderness on palpation of the sacroiliac joint areas and sciatic notch regions. The veteran stood flexed at 30 degrees with further active flexion to 45 degrees with a measuring device. Extension was to zero degrees. Reflexes of the lower extremities were all within normal limits. There was hypesthesia of the right lateral and medial calf. Straight leg raising was positive bilaterally from the supine position at 10 degrees. Examination of the cervical spine revealed a positive cervical pressure test. Active range of motion of the cervical spine was 25 degrees of flexion, 8 degrees of extension, 22 degrees tilt to the right and left and 30 degrees rotation to the right and left. A 2 3/4-inch anterior right horizontal scar was noted in the midneck region. Reflexes of the veteran's upper extremities were within normal limits. There were multiple well-healed surgical scars on both legs. There was a right arm scar in the anterior medial humerus region on the medial ulnar aspect of the right elbow and the anteromedial aspect of the right forearm. There was a positive Tinel sign just proximal to the scar on the medial portion of the elbow. There was hypesthesia in the ulnar nerve distribution of the right hand. The veteran was noted to be right handed and to squeeze 25 pounds less than with his left hand using a grip dynamometer. Range of motion of the right wrist, fingers, and elbows as well as the left upper extremity was completely normal. Examination of the left knee revealed an anterior vertical scar over the midportion of the patella. Range of motion of the knee was 0 to 110 degrees compared to 0 to 135 degrees in the right knee. There was atrophy of the quadriceps muscle and a positive patella test for pain. The ligamentous structures tested out normally. The entire knee joint was tender on palpation. X-rays were interpreted to reveal osteoarthritis of the cervical spine as well as solid fusion of the C5-C6 vertebral bodies. The lumbosacral spine showed osteoarthritic changes. The left knee showed early arthritic changes. The veteran was also noted to have retained multiple small shell fragments. On a VA peripheral nerve examination in January 1997 the veteran said that he had constant pain on the right side of his face which aches all the time with superimposed splitting headaches. He also said he has sharp pains if he presses on an area near his right cheek. He noted that he has nausea at times because of the shrapnel wounds to his abdomen. The veteran also complained of low back pain which was constant and radiating down to both lower extremities as well as weak muscles especially in the right upper extremity but also in his lower extremities and left upper extremity. Additionally, he complained of tingling in his legs and muscle spasms in his low back. He denied any bowel or bladder abnormalities. On neurological examination cranial nerves II through XIX were unremarkable, except for decreased facial sensation on his right midface area in the vicinity of his old scar. Motor examination showed that there was mild weakness of the right interossei in the right biceps about 4- plus/5 and also questionable weakness versus pain affecting effort in the right ankle dorsiflexion, eversion and extensor hallucis longus about 4 plus to 5 minus. Other groups in the right and left extremities were all 5/5 in power. Sensory examination showed diminished pinprick in the right upper extremity in the C6 territory and on the toes and legs diffusely with dysesthetic or paresthetic sensation of abnormal feeling when he was touched with a finger or pin on his toes on the right foot. The veteran was noted to be stooped over at the waist but he could walk on his heels and toes. He could also walk tandem with some effort. Romberg test was negative. In February 1997 the veteran was hospitalized at a VA medical center for abdominal pain of undetermined etiology. The veteran reported that over the past four days he had experienced pain with nausea and vomiting as well as diarrhea. Examination of the abdomen revealed a vertical midline and multiple transverse well-healed scars. There was soft positive tenderness on palpation in the right midabdomen. Bowel sounds were hypoactive. There was negative rebound or guarding. A three-way X-ray study of the abdomen was negative for dilated loops or air fluid levels. The veteran was hospitalized for observation overnight and put on MS Contin, which he tolerated quite well. He was able to tolerate a regular diet with no complaints and was discharged the following day. On VA examination in June 1997 the veteran complained of constant pain in the lower back radiating to the left testicle. He also complained of nausea and continuous pain in his stomach at times and vomiting. He indicated that his stomach always bothers him when eating. He further noted that his left knee hurts all the time and that he has decreased sexual performance because of pain and an inability to maintain position with his body. He further complained of right ankle pains, right shoulder pains and generalized pain. It was noted the veteran had suffered multiple scars, which were mostly superficial, well healed, disfiguring at some parts and affecting the veteran's general appearance. Physical examination noted scars to include a scar on the maxillary sinus on the right; lower neck, transverse; on the anterior chest; vertical below the umbilicus; on the right arm and right hand; transverse on the right side of the abdomen; left thigh; both knees; behind the right calf; and over the symphysis pubis. The left knee was noted to show full range of motion with no tenderness and no cracks. The veteran's right shoulder examination showed external rotation at 90 degrees. There was no more abduction above 90 degrees. The veteran's abdomen was soft, and benign with no organomegaly. The abdomen was very sensitive to touch and there was no rebound. The veteran had positive bowel sounds and no focal tenderness. The lungs were clear to percussion and auscultation. It was noted that the veteran had a barium test in February 1997, which showed increased partial small bowel obstruction in the jejunum. It was reported that the colon showed full coat of barium from the distal small bowel to the proximal sigmoid. The remainder of the bowel could not be evaluated for mass/lesions on this study, as it was not coated with barium. A hearing officer's decision in August 1997 increased the disability evaluation for the veteran's residual of a shrapnel wound of the right forearm from 10 to 30 percent disabling under Diagnostic Code 8516, effective from February 1995. In a statement received in October 1997 the veteran's spouse described the veteran's wounds, their appearance and the difficulties she and the veteran have had with discomfort caused by his multiple wounds. She specifically indicated that because of his wounds the veteran is unable to lay on his side and hug her, participate in certain sports activities or fully enjoy his grandchildren. She described the veteran's scars as disfiguring and severe. Private clinical records received in October 1997 show that the veteran was followed for problems with chronic low back pain since February 1995 and was noted in July 1997 to have significant recent improvement with medication adjustments. In June 1997 he was surgically evaluated for problems with increasing abdominal pain with nausea over the years as well as a recently developed new drainage area to a wound in the right abdomen. Examination of the abdomen revealed multiple abdominal scars and old healed incisions with an obvious healed abscess in the midline superior to the umbilicus. There was no evidence of emanating purulence or any cellulitis although a small open area on the medial aspect of an oblique incision measuring 5 centimeters long was noted. Abdominal tenderness and pain with a question of new enterocutaneous fistula was diagnosed. A computer tomography scan of the abdomen in June 1997 was negative for any abscess or identifiable intracutaneous fistula. The rectus muscle was noted to be disruptive and several bowel loops were found to be adherent to a region of subcutaneous sutures in the right midabdomen. An upper gastrointestinal series that same month was essentially negative except for a slight irregularity just beyond the duodenal bulb indicated to be due to a duodenitis or perhaps prior surgical intervention. In May 1999 the veteran presented for a hearing before the undersigned member of the Board. At this hearing, the veteran described ongoing problems with the shell fragment wound of the abdomen to include pain, constipation and intermittent diarrhea. He indicated that the stomach wound scar residuals drains and is subject to ulceration. He said that his abdominal scars were extremely tender, as were the scars in the upper and lower extremities. He said that over the years his disabilities have gotten much worse and are responsible for his unemployability as early as 1995. II. Analysis Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but also the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. Where an increase in an existing disability rating based on established entitlement of compensation is at issue, the present level of disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. A. Lumbar Spine The veteran is in receipt of the maximum disability rating under Diagnostic Code 5293 for intervertebral disc syndrome. We have considered evaluating this disability under other diagnostic codes applicable for disabilities of the spine to include Diagnostic Codes 5285, residuals of fracture of the vertebrae and Diagnostic Code 5286, complete bony fixation of the spine. The Board however notes that the veteran does not demonstrate any objective evidence of ankylosis of the spine or residuals of fracture of the vertebrae to warrant a higher schedular evaluation in excess of 60 percent. Accordingly a 60 percent evaluation accurately reflects the disability picture associated with the veteran's lumbar spine disorder. An increased schedular evaluation may not be assigned at this time. The Board further notes that neither the veteran nor his representative have argued that the schedular ratings are inadequate. The Board furthermore does not find exceptional or unusual circumstances such as to warrant referral to the RO for consideration of assignment of an extraschedular rating under 38 C.F.R. § 3.321(b) (1999). See Floyd v. Brown, 9 Vet. App. 88 (1996), Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). B. Cervical Spine Slight limitation of motion of the cervical segment of the spine warrants a 10 percent evaluation; moderate limitation of motion warrants a 20 percent evaluation, and severe limitation of motion warrants a 30 percent evaluation. 38 C.F.R. Part 4, Code 5290. Mild intervertebral disc syndrome warrants a 10 percent evaluation. Moderate intervertebral disc syndrome with recurring attacks warrants a 20 percent evaluation. Evidence of severe intervertebral disc syndrome with recurrent attacks and intermittent relief warrants a 40 percent evaluation. Evidence of pronounced intervertebral disc syndrome with persistent symptoms compatible with sciatic neuropathy, characteristic pain, demonstrable muscle spasm, absent ankle jerks, or other neurological findings appropriate to the site of the diseased disc and with little intermittent relief warrants a 60 percent evaluation. Diagnostic Code 5293. After reviewing the evidence of record the Board concludes that the preponderance of the evidence is against an evaluation in excess of 30 percent for the service-connected arthritis of the cervical spine. The evidence of record has demonstrated that in January 1997 the veteran's range of motion of the cervical spine was 25 degrees of flexion, 8 degrees of extension, 30 degrees of rotation, and 22 degrees tilt to the right and left with complaints of mildly severe pain radiating to both shoulders and arms. X- rays of the cervical spine showed osteoarthritis and a solid fusion of C5-C6 intervertebral bodies following the surgery in October 1993. The Board observes that the veteran is at the maximum evaluation under Diagnostic Code 5290, which contemplates severe limitation of motion of the cervical spine. While the Board is aware of the findings of C5-C6 fusion and is also aware of the United States Court of Appeals for Veterans Claims decision in Lewis v. Derwinski, 3 Vet. App. 259 (1992) (defining ankylosis as "immobility and consolidation of a part due to disease, injury, surgical procedure" we do not find fusion resulting in ankylosis is present. Despite the veteran's spinal fusion surgery, there is no competent evidence that his cervical spine is ankylosed. Range of motion of the cervical spine, albeit limited, is nevertheless demonstrated on the January 1997 VA examination. Accordingly, application of Diagnostic Code 5287, ankylosis of the cervical spine, is not warranted in this case. As to an evaluation on an alternative basis under Diagnostic Code 5293, the evidence shows that the veteran's neck pain was lessened by his surgery and that neurological deficits consist primarily of diminished sensation in the right C6 distribution. The medical evidence does not establish that the veteran has persistent symptoms compatible with sciatic neuropathy or does he have demonstrable muscle spasms. Accordingly disability as to warrant an increased evaluation under diagnostic code 5293 is not demonstrated. Thus, the Board has determined that a cervical spine disorder is no more than 30 percent disabling. In making this determination the Board has considered the guidance of DeLuca v. Brown, 8 Vet. App. 202 (1995). However, the analysis in DeLuca does not assist the veteran as he is receiving the maximum disability evaluation for limitation of motion of the cervical spine. See Johnston v. Brown, 10 Vet. App. 80, 85 (1997). C. Abdominal Wounds The veteran's service-connected shrapnel wounds of the abdomen are currently rated as 30 percent disabling under Diagnostic Code 7301 (adhesions of peritoneum). That rating contemplates a moderately severe disability, with partial obstruction manifested by delayed motility on barium meal and less frequent and less prolonged episodes of pain. A 50 percent rating, the highest rating assignable under this code, contemplates a severe disability with definite partial obstruction shown by X-ray, with frequent and prolonged episodes of severe colic, distention, nausea or vomiting, following severe peritonitis, ruptured appendix, perforated ulcer, or operation with drainage. Here the evidence of record shows that the original wounds led to "operation with drainage" as contemplated by the criteria for a 50 percent disability evaluation. The veteran testified that he experiences nausea, vomiting, periods of constipation and diarrhea as well as pain with pressure on the abdomen. As reported by VA examiners in June 1997 and July 1998, a February 1997 upper gastrointestinal series showed partial small bowel obstruction in the jejunum. His complaints and symptoms are said to be consistent with small bowel obstruction. It appears that the veteran's primary complaints with respect to his abdomen as indicated by his testimony consist of episodes of nausea and vomiting and abdominal pain with pressure contact. These symptoms and findings, given the veteran's history, more closely approximate the criteria for the 50 percent rating, which is granted. D. Right Forearm The veteran's residuals of a shrapnel wound to the right forearm has resulted in neuropathy of the right ulnar nerve and has been assigned a 30 percent disability evaluation under Diagnostic Code 8516. A 30 percent evaluation is warranted for incomplete paralysis of the major extremity (here the right forearm) where moderate incomplete paralysis is exhibited, while a 40 percent evaluation is warranted when severe incomplete paralysis is exhibited. A 60 percent evaluation is applicable when complete paralysis is shown, as manifest by "griffin claw" deformity due to flexor contraction of the ring and little fingers, atrophy very marked in dorsal interspace and thenar in hypothenar eminencies; loss of extension of the ring and little fingers, cannot spread the fingers (or reverse) cannot abduct the thumb; flexion of the wrist is weakened. A review of both the medical evidence and the veteran's testimony reflects that the veteran's disability resulting from the injury to his right forearm is not compatible with severe incomplete paralysis. Notably, while impairment of coordination was shown on VA examination in June 1995, sensory and motor status was normal and handgrip was only slightly decreased. The examiner who conducted his VA examination in January 1997 found that the veteran had only a moderate degree of ulnar nerve neuropathy with evidence on examination of hypesthesia. Motion of the wrist, fingers, and elbows of the right upper extremity were all normal. In sum, the veteran's right ulnar neuropathy resulting from the wound injury to the right forearm has not been characterized by his examiner as severe. The objective evidence of record does not disclose otherwise. Thus, the Board finds that the preponderance of the evidence is against the assignment of an evaluation in excess of 30 percent for the veteran's service- connected residuals of a shrapnel wound of the right forearm. In doing so, the Board acknowledges the veteran's testimony, proffered in August 1996. However, the subjective complaints of pain and numbness as well as fatigue while credible, do not rise to the level of severe incomplete paralysis. E. Chest Wound The veteran's shrapnel wounds of the chest are rated by the RO under the provisions of Diagnostic Code 5321, as injury to Muscle Group XXI, muscles of respiration. The Board notes that during the pendency of this appeal the rating criteria for muscle injuries were revised. See 62 Fed. Reg. 30327-28 (June 3, 1997). Where the law or regulation changes while a case is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991). Therefore, the veteran's increased rating claim will be considered under both the old and new law. A noncompensable evaluation is warranted for slight injury to Muscle Group XXI (thoracic muscle group). A 10 percent evaluation requires moderate injury. A 20 percent evaluation is warranted for severe or moderately severe injury. 38 C.F.R. Part 4, Code 5321. Moderate disability of muscles is contemplated when there is a through-and-through or deep penetrating wound of a short tract by a single bullet or a small shell or shrapnel fragment. There was no explosive effect of a high velocity missile and there are no residuals of debridement or prolonged infection. The objective findings include entrance and (if present) exit scars linear or relatively small and so situated as to indicate a relatively short tract through the muscle tissue. Objective findings also include signs of moderate loss of deep fascia or muscle substance or impairment of muscle tonus and of definite weakness or fatigue in comparative tests. 38 C.F.R. § 4.56(b), effective prior to July 3, 1997. Moderately severe disability of muscles is contemplated when there is a through-and-through or deep penetrating wound due to a high velocity missile or a large missile of low velocity, with debridement or with prolonged infection or with sloughing of soft parts and intermuscular cicatrization. The objective findings include relatively large entrance and (if present) exit scars so situated as to indicate the tract of the missile through important muscle groups. Other objective findings include moderate loss of deep fasciae or moderate loss of muscle substance or moderate loss of normal firm resistance of muscles compared with the sound side and marked or moderately severe loss of strength. 38 C.F.R. § 4.56(c), effective prior to July 3, 1997. Moderate disability of muscles is contemplated when there is a through-and-through or deep penetrating wound of short tract from a single bullet, small shell or shrapnel fragment, without explosive effect of a high velocity missile, residuals of debridement or prolonged infection. There is a service department record or otherwise evidence of in-service treatment for the wound. There is a record of consistent complaints of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lower threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. The objective findings include entrance and (if present) exit scars, small or linear, indicating a short tract of the missile through muscle tissue. There is some loss of deep fasciae or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2), effective July 3, 1997. Moderately severe disability of muscles is contemplated when there is a through-and-through or deep penetrating wound by a small, high velocity missile or large low velocity missile, with debridement, prolonged infection or sloughing of soft parts and intermuscular scarring. There is a service department record or other evidence showing hospitalization for a prolonged period of treatment of the wound. There is a record of consistent complaints of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements. The objective findings include entrance and (if present) exit scars indicating tract of the missile through one or more muscle groups. There are indications on palpation of loss of deep fasciae, muscle substance or normal firm resistance of muscles compared with the sound side. Test of strength and endurance compared with the sound side demonstrates positive evidence of impairment. 38 C.F.R. (NOT DICTATED) (d)(3), effective July 3, 1997. For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement. 38 C.F.R. § 4.56(c). The veteran's service medical records do not fully document the nature of the veteran's initial chest wound but indicate that penetration was to the soft tissues of the right anterior thorax and resulted in a contusion of the right upper lobe of the right lung. VA examination immediately after service did not show that the chest wound involved bony injury or muscle loss. The track of the missile was relatively short. This conclusion is based on the service medical records and VA X-ray evidence of fragments of steel indicated as close to the mediastinum and normal fully expanded lungs. There is no indication that there was an explosive effect related to this injury or any prolonged infection. Recent VA examination revealed clear lungs to percussion and auscultation. There was no evidence of impairment to respiratory muscle function related to the service-connected injury and the veteran has not testified otherwise. In essence, there is no evidence of a moderately severe disability with loss of muscle substance or strength. Therefore, the Board finds that a rating in excess of 10 percent under the criteria effective before and after July 1997 amendments for injuries to Muscle Group XXI is not warranted. F. Right Thigh The veteran's shrapnel wound of the right thigh is rated according to the criteria for paralysis of the sciatic nerve under Diagnostic Code 8520. Complete paralysis of the sciatic nerve is such that the foot dangles and drops, with no active movement possible of muscles below the knee, flexion of knee, weakened or (very rarely) loss will be rated as 80 percent disabling. Severe incomplete paralysis with marked muscular atrophy will be rated as 60 percent disabling. Incomplete paralysis will be rated as 40 percent disabling where moderately severe, is 20 percent disabling where moderate, and 10 percent disabling where mild. 38 C.F.R. Part 4, Code 8520. On private examination in February 1995, motor examination revealed normal and equal muscle strength of both lower extremities and a report of decreased sensation over the anterior proximal right thigh from the veteran's shrapnel wound. There were no other abnormal sensations. The veteran's VA examiner in June 1995 found the veteran's sensory and motor status to be normal without restriction. Neurological examination on VA hospitalization in February 1997 as well as examination of the extremities was essentially negative. The comprehensive January 1997 examination found diminished sensation in the lower extremities, however, such symptomatology was attributed by the VA examiner to the veteran's service-connected low back disorder as opposed to injury residuals to the sciatic nerve resulting from the service-connected right thigh wound. In sum, the medical evidence shows findings, which are no more than mild and which are limited to sensory deficits. Consequently, there is no basis for finding that there is moderate or greater paralysis resulting from the service-connected right thigh wound injury involving the sciatic nerve, which would permit increasing the disability rating currently assigned. G. Left Knee Shrapnel Wound The veteran's service medical records show that the shrapnel wound of the left knee result in a small fracture to the inferior pole of the left patella. X-ray of the left knee on initial VA examination in September 1971 disclosed shrapnel in the soft tissue with intact bony structure. Range of motion of the left knee was indicated to be unimpaired. Clinical findings were limited to a scar about the medial left knee indicated to be well healed and the veteran's complaints of left knee pain. The veteran's left knee on VA examination in June 1995 had grossly normal range of motion although tenderness with crepitation was noted in the left patella area. His scars were indicated to be well healed. The veteran's scars on VA examination in June 1997 were also noted to be well healed and his left knee had full range of motion without tenderness or cracks. In sum, the veteran is not shown to have any impairment of his left knee function as a result of his shrapnel wound injury and his scars are well healed. Diagnostic Code 7804 provides a 10 percent disability evaluation for scars which are superficial, tender and painful on objective demonstration. The veteran is currently assigned a 10 percent disability evaluation for his left knee injury residuals. No greater impairment is shown. Accordingly, a rating in excess of 10 percent for the left knee shell fragment wound injury residuals would not be in order. H. Face and Neck Scars Service medical records show the veteran sustained multiple fragment wounds within the soft tissues of the face. His facial scars were noted to be well healed in December 1969 and, after service, on VA examination in May 1971. On the latter examination the veteran's facial scars were noted to include a two-inch horizontal scar on the right cheek adjacent to the nose, not particularly sensitive to pressure although resulting in an area of diminished sensations centered about it. The veteran's facial and neck scars are rated as 10 percent disabling under the provisions of Diagnostic Code 7800. A 10 percent evaluation may be assigned under Diagnostic Code 7800 for the scars of a neck, face or head, which is moderate and disfiguring. The veteran's scars on the face and neck may also be assigned a 10 percent evaluation under the provisions of Diagnostic Code 7803 if the scar is fully nourished with repeated ulceration. A 10 percent evaluation may also be assigned under Diagnostic Code 7804 if the scar is tender or painful on objective demonstration. Under Diagnostic Code 7800, a 30 percent evaluation is warranted for a scar of the head, face or neck if such is severe, and especially if producing a mark and a slight deformity of the eyelids, lips, or auricles. The veteran's spouse has described the veteran's scars as disfiguring and has further stated that the veteran's appearance as a result of his scarring has worsened over the years. She however indicates that her comments pertain to the veteran's abdominal scars, chest scars, and neck as opposed to his facial scarring. On recent VA examination of the veteran's scars it was indicated they were mostly superficial and well healed. His VA examiner further observed that they were disfiguring at some parts (without reference to any specific anatomical location) and affecting the veteran's general appearance. Neurological examination was unremarkable except for decreased facial sensation in the vicinity of his old scar. The veteran in his December 1997 testimony indicated that he believed his scars should be compensated for tenderness. He further noted that "the ones that are worse are the ones that I'm not getting compensated for actually." Thus implying that impairment from his facial and neck scars was essentially unchanged. The veteran at his earlier hearing in August 1996 testified with respect to his facial scarring that his scars were now more visible than before and caused his cheek and the edge of his lip to droop. Notwithstanding the veteran's seemingly contradictory testimony, it is the Board's opinion that the clinical findings show no more than moderate disfiguring scarring which is neither painful nor tender. Accordingly, the Board concludes that an increased evaluation for the veteran's scars of the veteran's face and neck is not in order. I. Abdominal Scars and Scars of Both Upper and Lower Extremities Recent clinical findings fail to provide bases for assigning a compensable rating for the scars of the abdomen or upper and lower extremities. These scars were described on VA examination as mostly superficial and well healed. To the extent that they are disfiguring, such disfigurement is only compensable under the Rating Schedule for head, face, or neck scars. A stitch abscess in one of the abdominal scars was reported by Dr. Kuchirchik in May 1996, but examinations before and after that episode did not find repeated ulceration. As there is no evidence which reveals that these scars are predominantly other than asymptomatic, a compensable rating for scars of the abdomen as well as scars of upper and lower extremities is not warranted. In reaching this decision, the Board has considered the doctrine of granting the benefit of the doubt to the veteran and does not find that the evidence is proximately balanced as to warrant its application. ORDER An increased evaluation for arthritis of the lumbar spine with radiculopathy and limitation of motion due to shrapnel wounds is denied. An increased evaluation for arthritis of the cervical spine with limitation of motion due to shrapnel wounds is denied. Entitlement to a 50 percent evaluation for shrapnel wounds to the abdomen is granted, subject to regulations applicable to the payment of monetary benefits. Entitlement to an increased evaluation for shrapnel wound of the right forearm is denied. Entitlement to an increased evaluation for shrapnel wounds of the chest is denied. Entitlement to an increased evaluation for shrapnel wound of the right thigh is denied. Entitlement to an increased evaluation for wound scars of the face and neck is denied. Entitlement to an increased evaluation for shrapnel wounds of the left knee is denied. Entitlement to an increased (compensable) evaluation for scars of the abdomen, trunk, and chest is denied. Entitlement to an increased (compensable) evaluation for scars of both upper and lower extremities is denied. REMAND During the veteran's hearing before the undersigned in May 1999, he testified that he has been unemployable as a result of service-connected disabilities since 1995. He believes as such he should have been granted a total rating by the RO since 1995 based on individual unemployability resulting from service-connected disorders. The veteran's letter submitted at the hearing constitutes a notice of disagreement with respect to the RO's March 1999 rating decision denying him entitlement to individual unemployability from August 1995. The United States Court of Appeals for Veterans Claims has held that in such cases the correct procedure is for the Board to remand, not refer the issues to the RO for issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1992). Moreover, the Board notes that this claim appears to have originated as early as the VA Form 9 received May 30, 1996, in which the veteran stated "I can no longer work my job," and has been pending since that time. The veteran's service-connected disabilities were then rated, in combination, at 60 percent; as such, they satisfied the 60 percent threshold requirement of 38 C.F.R. § 4.16(a) (1996) for unemployability determinations, as they were all the result of multiple injuries incurred in action. § 4.16(a)(4). The RO should issue a statement of the case with respect to the denial of entitlement to individual unemployability due to service-connected disabilities. This should address the considerations raised in the preceding paragraph. The veteran should be advised of his appellate rights. If the veteran files a timely substantive appeal the RO should respond accordingly. Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Veterans Appeals for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1998) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. J. E. DAY Member, Board of Veterans' Appeals