Citation Nr: 1007653 Decision Date: 03/01/10 Archive Date: 03/11/10 DOCKET NO. 08-05 389 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for residuals of a back injury to include the cervical and lumbar segments of the spine. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Debbie A. Breitbeil, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from October 1945 to August 1947 and from November 1948 to February 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal of a rating decision in May 2007 of a Department of Veterans Affairs (VA) Regional Office (RO). In February 2009, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is in the record. In a decision in March 2009, the Board determined that new and material evidence had been presented to reopen the claim of service connection for a back disability, and remanded the case for additional development. As the requested development has been completed, no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268 (1998). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2009). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The current back disability to include degenerative disc disease of the cervical and lumbar spine first diagnosed after service beyond the one-year presumptive period, is unrelated to an injury, disease, or event of service origin. CONCLUSION OF LAW A back disability to include the cervical and lumbar segments of the spine is not due to injury or disease that was incurred in or aggravated by service; and a back disability as a chronic disease may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2009). The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claim. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. The notification requirements are referred to as Type One, Type Two, and Type Three, respectively. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided pre- and post- adjudicatory VCAA notice by letters, dated in February 2006, in March 2006, in June 2006, and in September 2007. In the notice, the Veteran was notified of the type of evidence to substantiate the claim of service connection, namely, evidence of an injury or disease or event, causing an injury or disease, during active service; evidence of current disability; and evidence of a relationship between the current disability and the injury or disease or event, causing an injury or disease, during active service. The Veteran was also notified that VA would obtain service records, VA records, and records of other Federal agencies, and that he could submit other records not in the custody of a Federal agency, such as private medical records, or with his authorization VA would obtain any such records on his behalf. The notice included the provisions for the effective date of the claim and for the degree of disability assignable. As for content of the VCAA notice, the documents substantially complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence), of Charles v. Principi, 16 Vet. App. 370 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112 (2004) (to the extent of pre-adjudication VCAA notice); and of Dingess v. Nicholson, 19 Vet. App. 473 (notice of the elements of a claim for service connection). To the extent the VCAA notice came after the initial adjudication the timing of the notice did not comply with the requirement that the notice must precede the adjudication. The procedural defect was cured as after the RO provided content-complying VCAA notice, the claim was readjudicated as evidenced by the statement of the case in January 2008 and the supplemental statement of the case dated in December 2009. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.). Duty to Assist Relevant to its obligation to assist a claimant, VA has also made reasonable efforts to identify and obtain relevant records in support of the claim. 38 U.S.C.A. § 5103A (a), (b) and (c). The RO has obtained the service treatment records, VA medical records and records from private medical providers identified by the Veteran to include the records of C.W., MD, J.F., MD, and S.P., MD. The Veteran has not identified any additionally available evidence for consideration. VA has conducted medical inquiry in an effort to substantiate the claim of service connection for a back disability. 38 U.S.C.A. § 5103A(d). The Veteran was afforded VA examinations in October 2007 and June 2009. As there is no indication of the existence of additional evidence to substantiate the claim, the Board concludes that the duty-to-assist provisions of the VCAA have been complied with. REASONS AND BASES FOR FINDING AND CONCLUSION Principles of Service Connection Service connection may be granted for disability resulting from injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service incurrence will be presumed for certain chronic diseases, including arthritis and disease of the nervous system, if manifest to a compensable degree within the year after active service. 38 U.S.C.A. § 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Notwithstanding the above, service connection may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). Facts The Veteran, who is the appellant, served on active duty from October 1945 to August 1947 and from November 1948 to February 1969. The service treatment records show that during the Veteran's second period of service, in March 1950, he was a passenger in a Jeep, which overturned, and he suffered a concussion. On hospitalization on the day of the accident, the findings included a right pelvic abrasion. Several days later he complained of back pain and an X-ray revealed no bony changes in the thoracolumbar spine or in the pelvis. He was discharged from the hospital and returned to duty after nine days. In May 1950, the Veteran complained of intermittent left- sided back pain after his Jeep accident. The physical examination and X-rays were negative, and the diagnosis was back pain of unknown etiology. He was given heat treatment. In May 1951, the Veteran reportedly had back pain and severe limitation of motion as a result of an automobile accident in March 1951. He was treated with heat, massage, and taping. On a physical examination for reenlistment purposes in November 1951, the Veteran's spine was clinically evaluated as normal. In May 1955, the Veteran sprained his back lifting a wooden treadway. In September 1955, he suffered a lifting-type injury and after a period of hospitalization for about two weeks, the diagnosis was acute lumbosacral strain. He was then placed on light duty and given a temporary physical profile, limiting his physical activities. At the time of a February 1956 physical examination, the Veteran's spine was clinically evaluated as normal. In 1956, the Veteran reported an injury to his back, and X-rays of lumbosacral spine in October 1956 revealed no bony abnormality. At the time of a July 1960 physical examination for reenlistment, the Veteran's spine was clinically evaluated as normal. In January 1964, the Veteran complained of back strain and it was noted as mild. At the time of an April 1964 periodic physical examination, there was no indication of a back abnormality. At the time of a physical examination for separation in November 1968, the Veteran gave a history of recurrent back pain since 1955. On an orthopedic consultation to evaluate the pain in November 1968, X-rays of the lumbosacral spine were negative. The impression was no orthopedic pathology. After service, the Veteran filed a claim of service connection for a back condition in May 1981. In support of the claim, the RO obtained VA records, dated in May 1981 and June 1981, when the Veteran was seen and evaluated for multiple complaints. These records show a complaint of neck pain but do not show a diagnosis of a disability of the cervical or lumbar segments of the spine. A subcutaneous mass, probably a lipoma, was removed from the neck region. Private medical records disclose that in January 1995 the Veteran complained of back problems since 1954, but his most recent episode started in January 1995. At that time in particular he had pain from the mid-thoracic back around to the chest. On physical examination he had tenderness in the mid-thoracic region. The impression was that there appeared to be compression in the mid-thoracic spine compared to the other vertebral segments. A bone scan was ordered to determine if this was a new compression fracture and then probably an MRI to see what the etiology might be. A bone scan was essentially negative, except for some changes in the shoulders and left knee, and the physician remarked that he saw no problems with the back. The physician also stated that the Veteran was an avid golfer and now presented with complaints of low back pain. Upon examination of the Veteran, the physician noted that it appeared he had a generic-type low back pain with no radicular component or numbness, that is, no neurological deficit. The Veteran was reassured that there were no serious problems with his back. In November 1995, the Veteran was involved in vehicle accident and on evaluation in December 1995, the Veteran's major complaint was neck pain and upper back pain. It was also noted that the Veteran had some longstanding, occasional low back pain without specific leg pain. X-rays showed severe foraminal narrowing and disc space narrowing in various levels of the cervical spine. The diagnosis was cervical spondylosis. A subsequent CT myelogram in December 1995 showed moderate to severe lumbar stenosis at L3-4 and degenerative changes throughout the cervical spine. In August 1997, the diagnosis was degenerative disc disease and lumbar stenosis, requiring surgery, consisting a lumbar diskectomy, laminectomy, and fusion. He had additional surgery on the lumbar spine in August 1998. In March 1999, the diagnosis was cervical spondylosis, requiring surgery, consisting of a cervical diskectomy, spondylectomy and fusion. In January 2006, the Veteran's history included cervical and lumbar surgery in the 1980s. On VA examination in October 2007, the diagnosis was multi- level lumbar fusion. The examiner expressed the opinion that there was a less than 50 percent likelihood that the condition resulting in the lumbar surgery was caused by or related to the documented in-service injury or to other issues related to service. The examiner's reasons included the following: there was a paucity of records of medical treatment of the low back in service; the nature of the documented injury in service in 1955 was apparently non- serious; there were negative findings on the discharge medical examination; and there was a long hiatus between the 1955 injury and back surgery after service. In February 2009, the Veteran testified that he sustained two in-service back injuries. The first was in March 1950 when a Jeep rolled over and the second was in May 1951 when he sprained his back lifting a heavy object. He stated that he has had continuous back pain since then. He stated that all of his post-service surgeries were performed by Dr. W, the first being in 1980 and that he had further surgery in 1997 and in 1998. In March 2009, the RO asked the Veteran to furnish medical records concerning his spinal surgery in the 1980s or provide authorization for VA to obtain the records on his behalf. The Veteran responded that two hospitals had no records and that a third hospital had records that only dated back to 1985 and all such records were given to Dr. W. (whose records are on file). On VA examination in June 2009, the VA physician noted the Veteran's back complaints and diagnoses in and after service and that the Veteran had cervical surgery in 1995 and in 1999 and lumbar surgery in 1997 and in 1998, but that the onset of cervical and lumbar spine pain was in the service and that it had become gradually worse. The examiner diagnosed cervical and lumbar degenerative disc disease. The examiner explained that although the Veteran had multiple episodes of acute low back pain in the service in the 1950s and into the early 1960s, he was unable to identify any complaint of low back pain between 1964 and 1995, and in fact there was a scan report of a normal lumbar spine in 1995. The examiner stated that it was extremely difficult for to conceive of a back injury that developed over a 40-year period from the 1950s through 1995 that resulted in a normal MRI at that time. Accordingly, the examiner expressed the opinion that the Veteran's lumbar problems were not related to service. As for the cervical spine, the examiner found that the first medical note was following a motor vehicle accident from which a diagnosis of cervical spondylosis was made in November 1995, and that this occurred nearly 30 years after service. He could therefore find no objective indication to link the cervical spine diagnosis and the Veteran's period of service, and he concluded that the Veteran's current cervical spine disability was not related to service. Evidentiary Standards VA must give due consideration to all pertinent medical and lay evidence in a case where a veteran is seeking service connection. 38 U.S.C.A. § 1154(a). The Veteran does not argue and the record does not show that the claimed disability was the result of participation in combat with the enemy, and the combat provisions of 38 U.S.C.A. § 1154(b) do not apply. Competency is a legal concept in determining whether medical or lay evidence may be considered, in other words, whether the evidence is admissible as distinguished from weight and credibility, a factual determination going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. The Board, as fact finder, must determine the probative value or weight of the admissible evidence. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005) (citing Elkins v. Gober, 229 F.3d 1369, 1377 (Fed.Cir.2000) ("Fact-finding in veterans cases is to be done by the Board")). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b). Analysis The service treatment records document a vehicle accident in March 1950 followed by complaints of lower back pain in March 1950, in May 1950, and in May 1951, and then a lifting-type injury in September 1955 followed by inpatient treatment for acute lumbosacral strain that was the reason for a temporary physical profile. However, there were insufficient manifestations to identify any permanent back disability or disease entity, as evidenced by the following: negative X- rays of the lower spine in March 1950, in May 1950, in October 1956, and in November 1968; a normal examination of the spine at the time of physical examinations in November 1951, in February 1956, in July 1960, and in April 1964; a diagnosis of an acute lumbosacral strain in hospitalization in September 1955; and no orthopedic pathology found in regard to the spine on an orthopedic consultation at the time of a separation physical examination in November 1968. Where, as here, chronicity may be legitimately questioned, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). After service, VA records, dating back to 1981, do not show any spinal complaint or diagnosis. It was not until 1995 that the Veteran was seen by private physicians in relation to back problems, which he reported had been ongoing since service. However, it was the thoracic segment of the spine that was problematic at that time, and the Veteran underwent a bone scan, which was negative for any spine abnormality. The Veteran also complained of low back pain at the time his bone scan results were reported, and the physician informed him that he had no serious back problems. The next reference to back problems was after the Veteran complained of neck pain following a motor vehicle accident later in 1995, and from that point onward diagnostic studies showed degenerative conditions affecting the cervical spine and the lumbar spine, which resulted in surgeries on the cervical and lumbar segments of the spine. The periods without documented complaints of back pain from 1969, when the Veteran was discharged from service, until 1995 interrupt continuity of symptomatology, which weighs against the claim. 38 C.F.R. § 3.303(b); Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (It was proper to consider the veteran's entire medical history, including a lengthy period of absence of complaints.). The Veteran had been seen at the VA for treatment in 1981, and had filed a claim of service connection for a "back condition" at that time, but there was no objective evidence of a spine disability then or for many years preceding 1981 or after 1981. In other words, this absence of evidence for a considerable period of years constitutes negative evidence tending to disprove the claim that the Veteran had an injury or disease in service that resulted in chronic disability or persistent symptoms thereafter. See Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom. Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (noting that the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact); see also Dulin v. Mansfield, 250 Fed. Appx. 338, 2007 WL 2914797 (C.A. Fed. Oct. 5, 2007) (The majority in Forshey interpreted negative evidence to mean that "which tends to disprove the existence of an alleged fact. The absence of evidence in support of an alleged fact clearly is an evidentiary circumstance that weighs against the existence of the alleged fact). Accordingly, the Board cannot conclude that a chronic disability relating to a disability of the cervical or a disability of the lumbar spine was actually demonstrated during service or that there is probative evidence of continuity after service, especially in light of the absence of complaints or findings in the ensuing years. In statements and testimony, the Veteran described ongoing and gradually worsening back pain ever since the in-service injury. The Veteran is competent to describe symptoms of back pain after service. Layno v. Brown, 6 Vet. App. 465, 470-71 (1994) (Lay testimony is competent evidence insofar as it relates to symptoms of an injury or illness.). As the Veteran's statements and testimony are competent evidence, the Board must also determine whether such evidence is credible. See Layno v. Brown, 6 Vet. App. 465 at 469. The Board, as fact finder, is obligated to determine the probative value or weight of the lay evidence in deciding whether there is continuity of symptomatology. In weighing the credibility, VA may consider self-interest, internal consistency, and consistency with other evidence. See Caluza v. Brown, 7 Vet. App. 478, 511 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996). The evidence against continuity of symptomatology consists of VA medical records in May 1981 and June 1981, which pertain to various health complaints but not one complaint of cervical or lumbar spine pain by the Veteran. A complaint of neck pain at that time resulted in the removal of a lipoma- like mass. The Veteran filed a claim for disability benefits with VA at that time, alleging a back condition, but the medical records contemporaneous with that filing do not show any complaint or diagnosis of a spinal condition. Here, the Veteran's statements and testimony of continuity of symptomatology are less probative, that is, the evidence is of lesser value to prove the existence of continuity than the negative evidence, as no symptoms were noted for many years after service and the Veteran's statements and testimony also lack credibility as when the Veteran was seen by VA in 1981, when he filed a claim for benefits, there was no history or complaint of a cervical or lumbar spine condition. In balancing the Veteran's statements and testimony against the absence of contemporaneous medical evidence of continuity of symptomatology and the inconsistent statements, the Board finds that the evidence against continuity is more credible than, and thus outweighs, the statements and testimony of continuity. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (absence of medical documentation may go to the credibility and weight of veteran's testimony, but the lack of such evidence does not, in and of itself, render the lay testimony incredible). The Board is not holding that corroboration by medical evidence is required, but the Board is permitted to weigh the absence of medical evidence against the lay evidence of record. See Buchanan, supra. For these reasons, the preponderance of the evidence is against the claim of service connection for a back disability to include the cervical and lumbar segments of the spine on the basis of continuity of symptomatology under 38 C.F.R. § 3.303(b). Also, degenerative changes of the cervical and lumbar segments of the spine by diagnostic testing in 1995 is well beyond the one-year presumptive period for manifestation of degenerative or arthritic changes as a chronic disease under 38 U.S.C.A. §§ 1112, 1131; 38 C.F.R. §§ 3.307, 3.309. As for service connection based on the initially diagnosis after service under 38 C.F.R. § 3.303(d), to the extent that the Veteran himself relates his current back disability to service, degenerative disease of the cervical and lumbar spine is not a condition under case law, where lay observation has been found to be competent, and therefore the determination as to the presence of the disability is medical in nature, that is, not capable of lay observation, and competent medical evidence is needed to substantiate the claim. See Savage v. Gober, 10 Vet. App. 488, 498 (1997) (On the question of whether the Veteran has a chronic condition since service, the evidence must be medical unless it relates to a condition as to which, under case law, lay observation is competent); see Barr v. Nicholson, 21 Vet. App. 303 (2007) (Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). Also, under certain circumstances, a layperson is competent to identify a simple medical condition. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (noting, in a footnote, that sometimes a layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer). Degenerative disc disease of the cervical and lumbar spine is not a simple medical condition, such as a broken leg, because the condition can not perceived through the senses and the identification or diagnosis of the condition, requires a person who is qualified through education, training, or experience to offer a medical diagnosis or opinion. For this reason, the Board determines that degenerative disc disease of the back is not a simple medical condition that a lay person is competent to identify. Where, as here, there is a question of a diagnosis, not capable of lay observation, and the claimed disability is not a simple medication condition, the Veteran is not competent to state that the current back disability was present during service. And while the Veteran is competent to report a contemporaneous medical diagnosis and the Veteran is competent in describing symptoms, which support a later diagnosis by a medical professional, there is no evidence from any health-care provider that attributes the current back diagnosis to an injury, disease, or event during the Veteran's service. For these reasons, while the Veteran's statements and testimony are to be considered, the evidence has no probative value, that is, the statements and testimony do not tend to prove a material issue of fact, pertaining to the onset of the disability during service. Also, where there is a question of medical causation, that is, an association between the current degenerative disc disease of the cervical and lumbar spine and an injury, disease, or event in service, where a lay assertion of medical causation is not competent medical evidence, Grottveit v. Brown, 5 Vet. App. 91, 93 (1993), competent medical evidence is required to substantiate the claim. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis or opinion. 38 C.F.R. § 3.159. In his statements and testimony, the Veteran relates his current back disabilities to an injury in service, which constitutes a lay opinion on causation, a lay opinion is limited to inferences which are rationally based on the Veteran's perception and does not require specialized knowledge. See generally Fed.R.Evid. 701 (opinion testimony by a lay witness is limited to inferences which are rationally based on the Veteran's perception and does not require specialized knowledge). Although the Federal Rules of Evidence do not apply to veterans' jurisprudence, recourse to the Federal Rules of Evidence is appropriate, where the Rules assist in the articulation of the Board's reason. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (Recourse to the Federal Rules of Evidence is appropriate where the Rules assist in articulation of the Board's reasons for finding a claim not well grounded.); Cf. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (Federal Rules of Evidence for evaluating expert medical opinion before U.S. district courts are important, guiding factors to be used by VA adjudicators in evaluating the probative value of a medical opinion.). As an opinion on causation in this case requires specialized knowledge, education, training, or experience, and as no factual foundation has been established to show that the Veteran is qualified through specialized knowledge, education, training, or experience to offer such an opinion on causation, his statements and testimony are not competent evidence and are not to be considered as favorable evidence in support of the claim. And while the Veteran is competent to report a contemporaneous medical diagnosis and is competent in describing symptoms, which support a later diagnosis by a medical professional, Jandreau at 1377, there is no evidence from any health-care provider that attributes the current diagnosis to an injury, disease, or event during the Veteran's service. On the determinative issue of medical causation, that is, the significance of the back complaints and findings in service in relation to the current back disability, competent medical evidence is required to support the claim, and VA obtained two medical examinations with opinions that address the issue. After a comprehensive evaluation of the record, the VA examiners in October 2007 and June 2009 have expressed the opinion that it was either less likely than not that the current low back disability was related to service or the cervical and lumbar spine conditions were not related to service at all. This medical evidence is uncontroverted. As there is no favorable competent evidence to support the claim as articulated above, the preponderance of the evidence is against the claim of service connection for residuals of a back injury to include the cervical and lumbar segments of the spine, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). ORDER Service connection for residuals of a back injury to include the cervical and lumbar segments of the spine is denied. ____________________________________________ George E. Guido Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs