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  1. Hey I'm new to the forum and really need help trying to understand what my last C&P means for my rating.. I have been waiting on this since 2010 on appeal and finally got a C&P after remand to RO. Can anyone tell me what possible rating I might receive Semper Fi. Neck (Cervical Spine) Conditions Disability Benefits Questionnaire Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No Evidence Comments: BOARD REMAND 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a cervical spine (neck) condition? [X] Yes [ ] No Cervical Spine Common Diagnoses: No diagnosis provided. Diagnosis #1: CERVICO-OCCIPITAL NEURALGIA ICD code: == Date of diagnosis: 9/28/2015 Diagnosis #2: CERVICAL RADICULOPATHY WITH BULGING DISC ICD code: == Date of diagnosis: 2016 Diagnosis #3: MECHANICAL CERVICAL PAIN SYNDROME ICD code: == Date of diagnosis: 4/29/2015 If there are additional diagnoses that pertain to cervical spine (neck) conditions, list using above format: CERVICAL VERTEBRAE(NECK MUSCLE SPASM), DATE OF DIAGNOSIS, 6/25/1996. CERVICAL HERNIATED AND BULGING DISC, MUSCLE SPASM, AND CORD CONTUSION WITH COMPRESSION MYELOMALACIA, 8/14/12 CERVICAL SPONDYLOSIS AND DEGENERATIVE DISC DISEASE, 9/25/2014. On today's C&P examination, 11/21/17, Veteran reports several incidents in 1992-1995 of blunt trauma including carrying 50 caliber machine gun barrels and ammunition. Involved in ground defensive tactic also known as "Bull in the Ring" in which the marine is in full gear and is potentially tackled by several marines. Following this , Veteran incurred concussion-1992 or 1993). Also went to Bethesda for back school(approx. week). Currently, Veteran reports daily neck pain. Denies neck surgery. Denies no recent physical therapy. Uses Flexeril, Ibuprofen, Oxycodone, and Tens unit for pain relief. Last treated by chiropractor in 2016(Tampa Bay, Florida). b. Dominant hand: [ ] Right [ ] Left [X] Ambidextrous c. Does the Veteran report flare-ups of the cervical spine (neck)? [ ] Yes [X] No d. Does the Veteran report having any functional loss or functional impairment of the cervical spine (neck) (regardless of repetitive use)? [X] Yes [ ] No If yes, document the Veteran's description of functional loss or functional impairment in his or her own words: Can't do much of any type of physical activity, that's really limited. Obviously a hindrance, job related stuff. Multiple days off from work(pain, stiffness). Can't do lawn activities. Can't wash dishes. Can't play with your kids like you want to. Sleeping is impossible-Sometimes you have to sleep sitting up in a chair. 3. Range of motion (ROM) and functional limitations --------------------------------------------------- a. Initial range of motion [ ] All Normal [X] Abnormal or outside of normal range [ ] Unable to test (please explain) [ ] Not indicated (please explain) Forward Flexion (0-45): 0 to 46 degrees Extension (0-45): 0 to 15 degrees Right Lateral Flexion (0-45): 0 to 23 degrees Left Lateral Flexion (0-45): 0 to 14 degrees Right Lateral Rotation (0-80): 0 to 48 degrees Left Lateral Rotation (0-80): 0 to 44 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes, (please explain) [ ] No If yes, please explain: Limited bending. Description of pain (select best response): Pain noted on examination and causes functional loss If noted on examination, which ROM exhibited pain (select all that apply)? Forward flexion, Extension, Right lateral flexion, Left lateral flexion, Right lateral rotation, Left lateral rotation Is there evidence of pain with weight bearing? [X] Yes [ ] No Is there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the cervical spine (neck)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): Tenderness on palpation of the cervical spine. b. Observed repetitive use Is the Veteran able to perform repetitive use testing with at least three repetitions? [ ] Yes [X] No If no, please provide reason: Unable to perform due to severe pain. c. Repeated use over time Is the Veteran being examined immediately after repetitive use over time? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran?s statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Please explain. [X] The examination is neither medically consistent nor inconsistent with the Veteran?s statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: This examiner is unable to opine and would otherwise be speculating to state whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. Therefore this examiner cannot describe any such additional limitation due to pain, weakness, fatigability or incoordination. Furthermore, such opinion is also not feasible to give degrees of additional ROM loss due to "pain on use or during flare-ups" without speculation. d. Flare-ups Not applicable e. Guarding and muscle spasm Does the Veteran have guarding, or muscle spasm of the cervical spine? [X] Yes [ ] No Muscle spasm [X] None [ ] Resulting in abnormal gait or abnormal spinal contour [ ] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: Guarding [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: f. Additional factors contributing to disability In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Less movement than normal due to ankylosis, adhesions, etc. Please describe: Decreased ROM. 4. Muscle strength testing -------------------------- a. Rate strength according to the following scale: 0/5 No muscle movement 1/5 Palpable or visible muscle contraction, but no joint movement 2/5 Active movement with gravity eliminated 3/5 Active movement against gravity 4/5 Active movement against some resistance 5/5 Normal strength Elbow flexion: Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Elbow extension Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Wrist flexion: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Wrist extension: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Finger Flexion: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Finger Abduction Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 b. Does the Veteran have muscle atrophy? [X] Yes [ ] No If muscle atrophy is present, indicate location: Upper Arm Provide measurements in centimeters of normal side and atrophied side, measured at maximum muscle bulk: Normal side: 37.5 cm. Atrophied side: 36 cm. 5. Reflex exam -------------- Rate deep tendon reflexes (DTRs) according to the following scale: 0 Absent 1+ Hypoactive 2+ Normal 3+ Hyperactive without clonus 4+ Hyperactive with clonus Biceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Triceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Brachioradialis: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ 6. Sensory exam --------------- Provide results for sensation to light touch (dermatomes) testing: Shoulder area (C5): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Inner/outer forearm (C6/T1): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Hand/fingers (C6-8): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent 7. Radiculopathy ----------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No If yes, complete the following section: a. Indicate location and severity of symptoms (check all that apply): Constant pain (may be excruciating at times) Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Intermittent pain (usually dull) Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Paresthesias and/or dysesthesias Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Numbness Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe b. Does the Veteran have any other signs or symptoms of radiculopathy? [ ] Yes [X] No c. Indicate nerve roots involved: (check all that apply) [X] Involvement of C8/T1 nerve roots (lower radicular group) If checked, indicate: [ ] Right [ ] Left [X] Both d. Indicate severity of radiculopathy and side affected: Right: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe Left: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe 8. Ankylosis ------------ Is there ankylosis of the spine? [ ] Yes [X] No 9. Other neurologic abnormalities --------------------------------- Does the Veteran have any other neurologic abnormalities related to a cervical spine (neck) condition (such as bowel or bladder problems due to cervical myelopathy)? [ ] Yes [X] No 10. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ----------------------------------------------------------------------- a. Does the Veteran have IVDS of the cervical spine? [X] Yes [ ] No b. If yes to question 10a above, has the Veteran had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months? [ ] Yes [X] No 11. Assistive devices --------------------- a. Does the Veteran use any assistive device(s) as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes [X] No b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 12. Remaining effective function of the extremities ---------------------------------------------------- Due to a cervical spine (neck) condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc.; functions of the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 13. Other pertinent physical findings, complications, conditions, signs, symptoms and scars ----------------------------------------------------------------------- a. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the Diagnosis Section above? [ ] Yes [X] No b. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis Section above? [ ] Yes [X] No c. Comments, if any: No response provided. 14. Diagnostic testing ---------------------- a. Have imaging studies of the cervical spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis (degenerative joint disease) documented? [X] Yes [ ] No b. Does the Veteran have a vertebral fracture with loss of 50 percent or more of height? [ ] Yes [X] No c. Are there any other significant diagnostic test findings and/or results? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): 9/25/2014,MRI Cervical spine:Visibility of the central canal of the cord at the C5 level with diameter of 2mm, not considered to reflect significant syringohydromyelia and not associated with mass or abnormal enhancement. Spondylosis and degenerative disc disease of the cervical spine. Right-sided predominant disc osteophyte complex at C6-7 causes mild right central canal and moderate right neural foraminal stenosis at this level. No other central canal stenosis with milder areas of neural foraminal encroachment detailed above. C2-3:Focal shallow central to right paracentral disc protrusion. No central canal or neural foraminal stenosis. C3-4:Mild generalized disc bulge. Mild right than left neural foraminal stenosis with central canal patent. C6-7:Mild generalized disc bulge with more focal disc osteophyte complex in the right paracentral, right subarticular, and right lateral stations. C7-T1:Negative for disc herniation. 8/14/2012, MRI Cervical spine:Herniated disk C3/4, C5/6, and C6/7 levels. Bulging disk C2/3 and C4/5 levels. Diffuse spondylitic changes. Straightened alignment suggesting muscle spasm. Focal area of cord contusion or compression myelomalacia at C5 level. 15. Functional impact ---------------------- Does the Veteran's cervical spine (neck) condition impact on his or her ability to work? [X] Yes [ ] No If yes, describe the impact of each of the Veteran's cervical spine (neck) conditions, providing one or more examples: Veteran is capable of limited lifting, carrying, and bending. 16. Remarks, if any: -------------------- NOTE:Veteran performed neck flexion repeition which reduced ROM to 32deg. Unable to perform any further repetition for other ROM maneuvers. ************************************************************************* Additional exam request information: For any joint condition, examiners should test the contralateral joint, unless medically contraindicated, and the examiner should address pain on both passive and active motion, and on both weightbearing and non- weightbearing. In addition to the questions on the DBQ, please respond to the following questions: 1. Is there evidence of pain on passive range of motion testing? YES 2. Is there evidence of pain when the joint is used in non-weight bearing? YES **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS Evidence Comments: BOARD REMAND MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: (a) Please state all diagnoses as to the Veteran's cervical spine, and address all diagnoses already of record: herniated disk and bulging disk of the cervical spine and spondylitic changes, muscle spasm and contusion/compression, spondylosis and degenerative disc disease of the cervical spine, mechanical cervical pain syndrome and radiculopathy. (b) Please provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any diagnosed cervical spine disability was caused by or etiologically related to active duty. Please specifically address the back injuries and complaints of back pain noted in the STRs. (c) Please specifically address the Veteran's lay statements that he has suffered cervical spine pain since service, and that in service he suffered injury to his neck while carrying heavy equipment and continuous wear of duty gear. (d) Please address the conflicting evidence of record and offer a clarifying opinion, notably the February 2013 VA examination positing a negative nexus, and the April 2016 private opinion positing a positive nexus. b. Indicate type of exam for which opinion has been requested: NECK TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: Upon review of all available medical evidence, including eVBMS, virtual VA, and Board Remand, the following pertinent information is obtained and reported in 'Evidence Comments': Prior VA Examination, 6/25/96, reports Mr. served in the Marine Corps. he was inducted in 1990 and received separation with an honorable discharge in 1996. Medical History-In 1992, he had onset of pain in the neck area diagnosed at Quantico. Xrays were negative. Impression was muscle spasm and stress. Enlistment RME/RMH for national guard, 4/13/98, reported no neck problems and normal exam of the spine. Miami VAMC, Outpatient clinic, 5/6/2005:Assessment is chronic neck and low back pain-Will get plain films and MRI, does not want any meds. 2/28/2013, VA examination opines "Unable to find SMR evidence of significant neck injury or complaint in service. No evidence to support chronicity of problem for over 10 years post-discharge." THIS OPINION IS GIVEN LOW WEIGHT BECAUSE IT IS NEITHER SUPPORTED NOR CONSISTENT WITH THE RECORDS IN FILE THAT SHOW COMPLAINTS OF NECK PAIN INDICATING A CHRONIC CONDITION. 4/29/15, DBQ neck was completed providing a diagnosis of mechanical cervical pain syndrome and radiculopathy. As received 4/8/16, VA physician, , states that the Veteran suffers from cervico-occipital neuralgia and cervical radiculopathy with bulging disc "are as likely as not a direct result of blunt trauma received during the patient's military career. His conditions are a severe occupational impairment to the veteran and has been exacerbated by many years of continuous wear of duty gear related to his profession." On today's C&P examination, 11/21/17, Veteran is a credible historian and reports several incidents in 1992-1995 of blunt trauma, involving ground defensive tactic also known as "Bull in the Ring" in which the marine is in full gear and is potentially tackled by several marines. Following this , Veteran incurred concussion-1992 or 1993). Veteran also reported chronic neck pain during service was due to carrying 50 caliber machine gun barrels and ammunition. He also went to Bethesda for back school(approx. week). In summary, the Veteran has been under chronic medical care for neck pain first reported during service(6/25/96) and the condition has progressed from cervical muscle spasm to mechanical cervical pain syndrome and radiculopathy, cervical herniated and bulging disc with muscle spasm, cord contusion/compression myelomalacia, cervical spondylosis and degenerative disc disease, cervico-occipital neuralgia, and cervical radiculopathy with bulging disc. A nexus has been established. Therefore, it is at least as likely as not that the claimed condition has direct service connection.
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