Citation Nr: 0842300 Decision Date: 12/09/08 Archive Date: 12/17/08 DOCKET NO. 06-29 421 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to service connection for residuals of a back injury. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Lindio, Associate Counsel INTRODUCTION The veteran had active duty service from July 1989 until October 1993. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a December 2005 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. FINDING OF FACT The veteran's degenerative disc disease of the lumbar spine had its onset in service. CONCLUSION OF LAW Degenerative disc disease of the lumbar spine was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2008). REASONS AND BASES FOR FINDING AND CONCLUSIONS In this case, the Board is granting in full the benefit sought on appeal. Accordingly, no discussion of VA's duty to notify or assist is necessary. The veteran contends that he injured his back during service, once while playing basketball, and a second time while he was deployed in the Gulf. Service treatment records indicate that the veteran was treated for a back injury in June 1990, following an initial injury 6 to 7 months earlier while playing basketball. A June 1990 x-ray found the veteran to have a normal lumbosacral spine series, and a July 1990 Physical Therapy record provided a provisional diagnosis of low back syndrome. The veteran continued to be treated for lower back pain until August 1990, when his examiner returned him to full duty. In August 1993, he received a Letter of Commendation for scoring an outstanding on his physical readiness test. His September 1993 separation examination noted that he had a normal spine and the veteran indicated he did not have recurrent back pain. In his March 2008 hearing testimony, the veteran also reported a second injury to his back while performing a reconnaissance mission in the Gulf, but that he never received medical treatment for that injury. He also reported that following service he was treated by his godmother, a chiropractor, for back pain. He contended that he has had continuous back pain since his initial injury. VA outpatient treatment records reflect that the veteran has sought treatment for recurrent back pain. An April 2005 VA outpatient entry shows that he complained of back pain and that a September 2004 spine film revealed no acute fracture or dislocation, with mild disc space narrowing at L5-S1. Posterior elements were unremarkable and the bilateral sacroiliac joints appeared normal. The examiner noted that an August 2004 MRI found mild bulging of the disc material at the L5-S1 interspace. A subsequent April 2005 VA Pain Control Consult Note states that the veteran to have chronic low back pain secondary to myofascial pain. A VA examination was provided in June 2007 and included a review of the claims file. The examiner noted that the veteran reported two back injuries and that he was treated for back spasms while in service. The veteran reported treatment by a chiropractor relative. He was also treated by VA for low back problems, which were being managed by the pain management group. The examiner found him to have a limited range of motion and found x-rays of the lumbosacral spine to reveal some narrowing of the L5-S1 disc space, while an MRI was essentially negative, showing only a mild bulge of the disc. The examiner diagnosed him with degenerative disc disease of L5. The July 2007 VA examiner found the basketball injury to be fairly minor and that the veteran's symptoms following service to be fairly constant. The examiner was unable to resolve the issue of whether his present condition was related to his problems in service without resorting to speculation. A private medical evaluation was provided by Dr. C.N.B., in April 2008, which did not include an examination of the veteran, but did include a review of the veteran's medical records. Dr. C.N.B. noted that the veteran the veteran's in- service back injury was a serious lumbar spine injury, with a loss of reflexes (knee and ankle-Achilles), per his service treatment records. The examiner found that the veteran's current lumbar spine problems were due to his service, noting that the veteran was fit for service when he entered service and that medical evidence supported that an injury such as the veteran's precipitates or accelerates the onset of the degenerative process of the spine. The examiner further noted that it was well known that injuries to the spine early in life often lead to advance degenerative changes later in life, due to the resultant chronic ligament laxity and spine instability. The evidence demonstrates that the veteran is currently diagnosed with a back disorder. Although the July 2007 VA examiner found linking the veteran's current back disorder to service would be speculative, Dr. C.N.B. found that the in- service back injury was more likely than not the cause of his current back disorder. Dr. C.N.B. thus found a nexus between the veteran's service and his current back disorder. As the evidence of record is at least in equipoise, the benefit of the doubt rule applies. Gilbert v. Derwinski, 1 Vet.App. 49, 58 (1991). As such, service connection for degenerative disc disease of the lumbar spine is granted. ORDER Service connection for degenerative disc disease of the lumbar spine is granted. ______________________________________________ STEVEN D. REISS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs