Citation Nr: 1305086 Decision Date: 02/12/13 Archive Date: 02/21/13 DOCKET NO. 10-15 439 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for degenerative disc disease, lumbar spine. 2. Entitlement to service connection for coronary artery disease and hypertensive heart disease, status post myocardial infarction and bypass surgery, as secondary to degenerative disc disease, lumbar spine. 3. Entitlement to service connection for hypertension, as secondary to degenerative disc disease, lumbar spine. 4. Entitlement to service connection for renal dysfunction, as secondary to degenerative disc disease, lumbar spine. 5. Entitlement to service connection for spinal osteomyelitis, as secondary to degenerative disc disease, lumbar spine. REPRESENTATION Appellant represented by: E. Clifton Williams, Esq. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jason A. Lyons, Counsel INTRODUCTION The Veteran served on active duty from January 1968 to December 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, denying the benefits sought. Jurisdiction over this case was later transferred to the RO in Winston-Salem, North Carolina. A Travel Board hearing was held in July 2012 before the undersigned Veterans Law Judge, the transcript of which is of record. At this hearing, the Veteran's attorney provided additional evidence consisting of a written brief, copies of private and VA medical evidence, and lay witness statements from other individuals, accompanied by a waiver of RO initial consideration as the Agency of Original Jurisdiction (AOJ). This evidence is hereby accepted for inclusion in the record. See 38 C.F.R. §§ 20.800, 20.1304 (2012). The Veteran's attorney through a written brief dated June 2012 further raises the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). According to the Veteran's attorney, the Veteran himself had previously referenced the fact that he "could hardly walk" due to his claimed conditions and that he was already "100 percent disabled through Social Security." The Board agrees that these findings appear to raise a claim for TDIU by the Veteran, and at the very least the Veteran's attorney has directly raised such an issue. However, the matter of entitlement to a TDIU has not been first adjudicated by the RO. Therefore, the Board does not have jurisdiction over the claim, and it is referred to the RO for appropriate action. The Board presently decides the claims for service connection for degenerative disc disease of the lumbar spine, hypertension and renal dysfunction. The remaining claims on appeal are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. The preponderance of the competent evidence establishes that the Veteran's degenerative disc disease of the lumbar spine manifested due to an incident of his military service. 2. The Veteran's renal dysfunction is proximately due to or the result of his service-connected lumbar spine disorder. 3. The Veteran's hypertension is proximately due to or the result of his service-connected lumbar spine disorder. CONCLUSIONS OF LAW 1. The criteria are met to establish service connection for degenerative disc disease of the lumbar spine. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). 2. The criteria are met to establish service connection for renal dysfunction, as secondary to degenerative disc disease, lumbar spine. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). 3. The criteria are met to establish service connection for hypertension, as secondary to degenerative disc disease, lumbar spine. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Duty to Notify and Assist the Veteran The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103A, 5107, 5126 (West 2002 & Supp. 2012), prescribes several requirements as to VA's duty to notify and assist a claimant with the evidentiary development of a pending claim for compensation or other benefits. Implementing regulations were created, codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326 (2012). As indicated below the Board is granting the benefits sought on appeal of entitlement to service connection for degenerative disc disease of the lumbar spine, hypertension, and renal dysfunction. Hence, even assuming, without deciding, that any error was committed as to implementation of the VCAA's duty to notify and assist provisions, such error was harmless in its application to adjudication of this matter, and need not be further discussed. See Bernard v. Brown, 4 Vet. App. 384 (1993). See also Mayfield v. Nicholson, 19 Vet. App. 103, 128 (2005), affirmed, 499 F.3d 1317 (Fed. Cir. 2007). Governing Law and Regulations Generally, service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C.A. § 1110 (West 2002 & Supp. 2012); 38 C.F.R. § 3.303(a) (2012). Service connection may also be granted for a disease diagnosed after discharge, where all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). The elements of a valid claim for direct service connection are as follows: (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999). Also of application to claims for direct service connection is the principle that where a chronic disease is shown during service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. On the other hand, continuity of symptomatology is required where the condition noted during service is not shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. Under the latter circumstances, a showing of continuity of symptomatology at the time of service discharge and continuing thereafter is required to support the claim. 38 C.F.R. § 3.303(b). The applicable VA law further provides for secondary service connection. In this regard, service connection may be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). In addition, a claimant is entitled to service connection on a secondary basis when it is shown that a service-connected disability has chronically aggravated a nonservice-connected disability. See 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). Under 38 C.F.R. § 3.310(b), any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service-connected. In reaching this determination as to aggravation of a nonservice-connected disability, the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected condition) is compared to the current level of severity of the nonservice-connected disease or injury. The evaluations of baseline and current levels of severity are to be based upon application of the corresponding criteria under the VA rating schedule for evaluating that particular nonservice-connected disorder. See Notice, 71 Fed. Reg. 52,744-47 (Sept. 7, 2006), later codified at 38 C.F.R. § 3.310(b). Moreover, lay statement evidence may have direct relevance to establishing underlying components of a claim for service connection. In Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the U.S. Court of Appeals for the Federal Circuit (Federal Circuit Court) commented that competence to establish a diagnosis of a condition can exist when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Lay testimony is deemed competent evidence with regard to matters within the purview of direct observation and firsthand knowledge. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is considered competent to report on that of which he or she has personal knowledge). Lay testimony where found credible is also competent to establish the presence of continuity of symptomatology for a claimed disability during and since separation from military service. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) further held in Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010) and in Waters v. Shinseki, 601 F.3d 1274, 1278 (2010), that it is error to suggest that lay evidence can never be sufficient to satisfy the requirement of 38 U.S.C.A. § 5103A(d)(2)(B) that there be a nexus between military service and a claimed condition. Factual Background The Veteran's service treatment records (STRs) include his January 1968 entrance examination which was negative for any indication of a back disorder. These records further provide a January 1968 clinical entry indicating that he was seen following having fallen "backwards over several logs this A.M. with resultant [illegible] lumbar pain [illegible]..." The assessment was of back pain. Thereafter, a March 1968 entry states "Third week AIT [Advanced Intermediate Training]. Injury to L-S spine [at] 14 years old. Lately pain increased with walking, running. 25 percent limitation flexion, otherwise negative." A November 1968 x-ray for trauma to the lumbosacral spine was negative. The Veteran's November 1969 separation examination did not include mention of a back disorder. Subsequently, VA medical records dated from May 1979 document that "two days ago [the Veteran] suddenly developed acute low back pain while running; has past history of acute back pains - never so severe." The diagnosis given was of acute low back syndrome. Thereafter, low back complaints are noted in VA outpatient records dated from August 1995, June 1996 and August 1996. The medical records from the Veteran's January 1999 lower back surgery are on file. This includes the March 1999 discharge summary, which states a final diagnosis of discogenic low back pain, status post L3 to sacrum fusion, with postoperative wound infection. The report documents the Veteran's incident of postoperative staph aureus infection. Ultimately, after further treatment including surgery and antibiotics, the Veteran was discharged to home care with oral analgesics and intravenous antibiotics. A May 1999 letter from Dr. T.J.D., private physician, recounts how in January 1999 the Veteran had undergone a three-level fusion of the lumbar spine from L3 to the sacrum with spinal instrumentation, and unfortunately a post-operative complication arose in terms of a wound infection, identified as staphylococcus aureus infection. Treatment entailed surgical debridement along with intravenous antibiotics followed by oral antibiotics with monitoring in the post-operative period. To summarize the report, the physician essentially recommended a new surgery for treating the infection (which the Veteran later underwent). In his October 2006 treatment summary, Dr. T.J.D. indicated that based on review of the Veteran's chart and history, it was his medical opinion that there was a definite consequential injury to the Veteran's lower back, which was initiated from injuries he sustained during military service. It was noted that the Veteran gave a timeline of care directed to the lower back from the initial date of injury at age 18. The November 2007 letter from H.B.K., a private chiropractor, states that the Veteran had been under his care for a low back complaint in mid-1996, where he was being treated for large herniations at the L4-5 and L5-S1 levels. Through his February 2008 correspondence, Dr. M.L.G., a VA physician at Northport, New York VA Medical Center (VAMC), indicated that the Veteran was his patient from 2002 to 2004, and at that time the Veteran was being followed for hypertension, chronic renal insufficiency, and chronic back pain. It was the understanding of this physician that the Veteran's back problems originated during his years in the service. The Veteran required several surgical procedures for this in 1999, complicated by post-operative infection and osteomyelitis, requiring prolonged treatment with a variety of antibiotics. It was also the understanding of this physician that one or more of these antibiotics contributed to the Veteran's developing renal insufficiency, a known complication of this type of treatment. It was also common that renal injury could lead to hypertension, or exacerbate existing hypertension. It was therefore this physician's opinion that it was more likely than not that the Veteran's renal insufficiency and hypertension were related to his original service-related back problems. The February 2008 letter from R.G., private chiropractor, recounts that the Veteran was treated for chronic lower back pain and intermittent leg pain from November 1985 through April 1987. Over that period of time the Veteran received chiropractic manipulative therapy as well as various physical therapy modalities, and responded moderately well to the treatment, but due to the chronicity of his pain pattern did not reach 100 percent recovery under care in his office. The February 2008 statement of Dr. A.R., private physician, indicates that the Veteran was manifesting stage IV kidney failure and was being followed regularly by a kidney specialist. This was an advanced level of kidney failure which might progress in the future to require dialysis or a kidney transplant. In a February 2008 lay statement, the Veteran's brother indicated that to his knowledge the Veteran had twice injured his back while in the military. According to the author of the statement, when the Veteran returned home from service, they lived under the same roof and the entire family was aware of the Veteran's injured back because of the restrictions it placed on him (walking, chores, etc.). Through his March 2008 correspondence, Dr. T.J.D. indicated that the Veteran was under his care between 1997 and 1999. The Veteran had undergone surgical intervention in terms of L3 to sacrum fusions with L5-S1 hemilaminectomies in January 1999, for treatment of mechanical low back pain secondary to herniated discs and spinal stenosis. He unfortunately developed postoperative wound infections, which were treated with incision and drainage. He later underwent an anterior lumbar interbody fusion at the L5-S1 level for discitis in June 1999. According to this physician, based on the Veteran's chart and clinical history, it was his medical opinion that a medical nexus existed between basic training injury while in service, and the Veteran's back surgeries in January 1999. It was noted in this regard that the Veteran gave a timeline of care directed to the lower back from that initial date of injury at age 18 and on until he eventually underwent surgical intervention in 1999. In a March 2008 lay statement, the Veteran's spouse recounted that she had known the Veteran since they were in high school together, and recalled him having had problems with his back after he returned from service. She recalled that soon after their marriage in 1990, the Veteran was in constant pain and various palliative measures did not alleviate his condition. Eventually the Veteran turned to surgery, and while in surgery contracted a deep wound staph infection in his lower spine, for which he eventually was again hospitalized. The Veteran's spouse recounted that the next seven months included two additional operations, and three months of home administered intravenous antibiotics. A physician had informed them that the use of the antibiotics led to kidney problems, which then contributed to carotid artery surgery, a heart attack, and a triple bypass. In her March 2008 statement, the Veteran's sister indicated that to her knowledge the Veteran was injured during his training in military service and returned home with a bad back, and that she learned of this when visiting the Veteran soon after he returned from overseas. Through his March 2008 lay statement, the Veteran himself described the circumstances of his in-service injury, stating that he was in the woods training with pugil sticks (the pugil stick being a padded, pole-like training weapon). The training area was enclosed by sandbags stacked three feet high. Initially, one at a time the Veteran beat the three individuals chosen to compete against him with the pugil sticks. Then the drill sergeant placed two individuals in the training area to compete against the Veteran simultaneously. When the training exercise commenced, these two people together attacked and defeated the Veteran. At the end of the exercise the Veteran fell backwards at a bad angle on top of the sandbags very hard and wrenched his back. The Veteran was immediately in pain, and eventually a jeep showed up and took him to the base hospital. According to the Veteran, he had experienced trouble with his back ever since this incident. The aforementioned injury was during basic training. He then had a recurrence of this injury during Advanced Infantry Training. Following service discharge, the Veteran recalled, he soon afterwards went to see his family physician, who recommended placing heat on the area and bed rest. The Veteran further described his later complications from back vertebral fusion surgery, when he developed a deep wound staph infection and vertebral osteomyelitis. To remove the infection, the treating physicians had to use antibiotics that damaged the Veteran's kidneys. His creatinine level went up to 335 percent and he had acute renal failure. Meanwhile, there was a prolonged active infection. The Veteran spent the next three months on intravenous antibiotics for three to four hours a day. According to the Veteran, the damaged kidneys proceeded to cause other health problems. The Veteran also submitted in March 2008 copies of several medical research studies accompanying his lay correspondence, some of which demonstrate the commonality of drug-induced renal disease, as well as general complications of renal disease. In his June 2008 statement, an individual who had military service alongside the Veteran indicated that he recalled meeting the Veteran at a post PX (i.e., a commissary on a military base) on an afternoon during their basic training. The author of the statement specifically recalled that the Veteran was limping. When he inquired, the Veteran explained he was limping from back pain, because he had injured his back during pugil stick training. Recently, the Veteran had stated that he did not recall this day, but the author of the statement had no doubt about the meeting, nor where it took place and the circumstances of their conversation. In his October 2008 statement, the Veteran explained that his private family physician had treated him continuously for back pain during the 1970s, and that records pertaining to this treatment course were no longer available. The Veteran underwent VA Compensation and Pension examination of the spine in December 2008. Following a thorough physical examination, the diagnosis given was degenerative disc disease, degenerative joint disease of the lumbar spine. The VA examiner then expressed the opinion that this condition was less likely as not caused by or a result of military service. The stated rationale was that no diagnosis of degenerative disc disease, or degenerative joint disease of the lumbar spine was made while in service. No diagnosis of any chronic low back condition was made while in service. A lumbar spine radiograph following acute low back injury from November 1968 was normal. Spine examination on separation examination was recorded as "normal," and medical history on separation examination noted "no" to the question of recurrent back pain. The earliest documentation identified, for treatment for a low back condition after separation from service, was in 1979 for "acute back syndrome" which developed while "running." In a more recent lay statement of April 2010, the Veteran's sister indicated her recollection that when the Veteran returned from service he was always on the couch because he said that his back was bothering him. She indicated that the Veteran at that time related that his back pain started when he was injured in pugil stick training during basic training. The Veteran's back problem just became common family knowledge at that point. Another recollection related to the Veteran's back was how he had a different stance when he came back from service, and carried himself differently due to back pain. In her April 2010 lay statement, the Veteran's spouse indicated that she remembered that the Veteran complained of back pain often when he returned home from service. She knew that he dealt with this pain by sleeping on a board in his bed, and used a hot water bottle on his back to relieve the back pain. She recalled that he sought medical care from 1969 to at least 1979 for his back problems from his family physician. The March 2011 follow-up correspondence from Dr. M.L.G., VA physician, indicates having had the opportunity to review the Veteran's claims file, as well as again notes prior treatment of the Veteran from 2002 to 2004. The VA physician expressed the opinion again that the Veteran's renal insufficiency and hypertension were more likely than not caused by the Veteran's service-related back injuries sustained during military service. According to the physician, the Veteran's medical history (as well as family history) reflected no kidney problems or problematic hypertension until he was treated in 1999 and later with prolonged antibiotic treatment of postoperative infection in his spine. This course of surgical intervention was undertaken because of prolonged, chronic lower back problems highlighted by mechanical lower back pain in the lumbar region which seemed to begin while the Veteran served in the late 1960s. The records further showed that the initial back injury which produced his back pain was most likely caused by a training event where the Veteran was repeatedly hit in the back, causing him to fall backward over a pile of sandbags. This opinion was further supported by the fact that neither the Veteran nor his family members reported any history of observable back problems prior to military service, as well as the fact that the Veteran's induction physical showed no signs of back problems. Moreover, shortly after surgical intervention, the Veteran exhibited symptoms of acute renal injury most likely caused by aminoglycoside antibiotics, the use of which was confirmed by the Veteran's records. This renal damage likely caused, or contributed to, the Veteran's increased hypertension which was also well-documented in his claims file and associated medical record. According to the physician, renal damage could cause hypertension, or worsen existing hypertension. This opinion was supported by the fact that there did not appear to be any other significant risk factors for either renal injury or hypertension in the Veteran's record or subjective history, nor was there a notation in his induction physical for either problem. It was concluded that the Veteran's renal insufficiency and hypertension were more likely than not caused by the Veteran's back injuries sustained during military service. The April 2011 statement from a former employer recalled that when the Veteran worked for his company from 1970 to 1980, he personally spoke with the Veteran on several occasions about the Veteran's back pain. In his follow-up correspondence of May 2011, Dr. T.J.D., private physician, reiterated that in light of his experience in the field of orthopedic medicine, his discussions with the Veteran, and his opportunity to review the claims file, it was his medical opinion that it was more likely than not that the Veteran's initial back trauma during military training caused his chronic mechanical low back pain (continuing uninterrupted for many years), secondary to what was believed to have been a herniated disc injury. The stated rationale noted consideration of the circumstances of original injury (during pugil stick training), documentation of in-service injury therein, and post-service treatment records for back problems. Further noted was the lack of other documented back problems prior to military service, the Veteran's age at the time of initial injury, and the consistency of symptoms over the years in light of objective and subjective evidence in the Veteran's records. The July 2011 letter from a family friend likewise recounted the Veteran's complaints of back problems that he attributed to an accident from basic training, beginning around 1970. Analysis A. Lower Back Disorder Having duly considered the foregoing, the Board is of the opinion that the criteria for service connection for degenerative disc disease of the lumbar spine are objectively met. In reaching this conclusion, the Board considers the essential elements to establish service connection to have been sufficiently demonstrated by objective evidence of record. The fact of the current existence of a low back disability never being in doubt, the Board's analysis centers upon the dispositive issue of whether degenerative disc disease is causally related to an incident of the Veteran's military service. This is the indispensable element for service connection of a causal nexus. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service."); Hickson, supra. See, too, Duenas v. Principi, 18 Vet. App. 512, 516 (2004). There is sufficient basis to convincingly demonstrate a causal nexus in this case, by appropriate evaluation of all competent medical records, post-service medical opinion evidence, and lay witness testimony, and in view of the Board's province to weigh the respective evidence before it on the determinative subject of causation. To begin with, the Veteran had documented in-service injury, and notably, by description from 1968 medical records one wholly consistent with his assertions of being injured when falling over sandbags surrounding the area of pugil stick training, where he unfortunately developed back problems. Though one STR denoted a possible injury pre-existing service from when the Veteran was age 14, there was never any notation of the same on induction, or otherwise clear indication of a disabling condition pre-existing service, such as to rebut the presumption of sound condition at service entrance generally afforded to claimants under 38 U.S.C.A. § 1111. As stated, there are several additional competent lay accounts of the underlying injury -- from the Veteran's own statements and hearing testimony, to the account of family members whom the Veteran informed soon after service, to the particularly credible statement of a fellow serviceman who remembers seeing the Veteran having difficulty moving in service due to back pain. Thus, in-service injury is established. There clearly was a pronounced back injury in service. This initial review is part of the causal nexus determination, but further showing must be made linking in-service injury with current disability. That additional prerequisite is likewise met in this case. On this subject, the Veteran has demonstrated a continuity of symptomatology from service discharge onwards. The first actual documentation of post-service back problems available for review is dated in 1979, about a decade post-service, but it warrants mention in this regard that the Veteran also reportedly had treatment for back problems during the 1970s from a private physician from whom records cannot be retrieved. In any event, there is a definitive lay witness history of lower back complaints and problems dating as far back as to 1970, established by several individuals who knew the Veteran well during that period. The Board notes that these statements are persuasive, credible, and internally consistent, and together help provide a picture of ongoing disability from service. See Barr, supra. See also 38 C.F.R. § 3.303(b) (addressing the continuity of symptomatology requirement to demonstrate causal relationship to service, where an in-service condition is not chronic); Clyburn v. West, 12 Vet. App. 296, 302 (1999). Moreover, the Board assigns appropriate probative weight to the array of medical opinion evidence in this case -- opinions from both VA and private former treatment providers who expressed the viewpoint that the Veteran's present disability of the lumbar spine originated as the direct consequence of his in-service injury to the lower back. Both opinions are substantiated through a claims file review, as well as a rationale that accounts for the pattern of back problems during and since military service. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (factors for assessing the probative value of a medical opinion include the medical expert's access to the claims file and the thoroughness and detail of the opinion); Boggs v. West, 11 Vet. App. 334, 340 (1998). Whereas the Board's evidentiary review notes the contrary December 2008 opinion of a VA examination, it is important to observe that there was an underlying inherent limitation in that the VA examiner only addressed the extent (or lack thereof) of documented medical history apropos of the extensive lay witness history of an ongoing back ailment, including from the Veteran himself. Regardless, at the very least, the Board's benefit-of-the-doubt doctrine mandates that reasonable doubt on the subject of causation be resolved in the Veteran's favor, and under this doctrine there is already sufficient positive evidence on medical causation to substantiate the requisite nexus to the Veteran's military service. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Therefore, in light of all pertinent findings of record, the Board deems the criteria for service connection for degenerative disc disease of the lumbar spine to have been met. B. Renal Dysfunction and Hypertension The Board finds by review and analysis of the evidence that there is support for the conclusion that both renal dysfunction and hypertension developed secondary to the Veteran's adjudicated service-connected disability of the lower back. Therefore, the Board is granting service connection for both claimed disabilities. There is essentially sufficient basis upon which to find that the Veteran's renal dysfunction and hypertension originated as a direct consequence of the Veteran's 1999 lumbar fusion surgery intended as treatment for his underlying back disorder, when he acquired a post-operative infection, and he was administered antibiotics over an extended time period with the resultant effect of diminishing his renal function, which later itself brought upon (and/or aggravated) his hypertension. This very causal chain of events is confirmed to have most likely occurred through the March 2011 VA medical opinion of Dr. M.L.G., who not only reviewed the claims file, but also directly treated the Veteran for several years. The opinion rationale contemplates that the Veteran never experienced kidney problems or serious hypertension up until the 1999 surgery and postoperative complications, and moreover, following the surgery was given aminoglycoside antibiotics for the infection for several months, which were known to have side effects of renal damage. The renal dysfunction in the VA physician's view had then either caused hypertension, or worsened existing hypertension, indicating a scenario under which in either instance service connection would be warranted. See 38 C.F.R. § 3.310(b) (service connection available for chronic aggravation of a nonservice-connected disorder by a service-connected disorder). See also Anderson v. West, 12 Vet. App. 491, 495 (1999), citing Libertine v. Brown, 9 Vet. App. 521, 522 (1996). These factual findings by competent opinion are persuasive, consistent with the record as a whole, and further, not contradicted by any other evidence on file. The Board hereby accepts this opinion as a probative clinician's statement on the unintended consequences of treatment for the underlying service-connected lumbar spine disability, and finds that service connection for both renal dysfunction and hypertension are warranted. ORDER Service connection for degenerative disc disease, lumbar spine, is granted. Service connection for hypertension, as secondary to degenerative disc disease, lumbar spine, is granted. Service connection for renal dysfunction, as secondary to degenerative disc disease, lumbar spine, is granted. REMAND The Board deems further development warranted on the remaining claims on appeal. Where necessary in order to properly decide a claim, VA's duty to assist requires that VA afford the claimant a VA Compensation and Pension examination. See 38 U.S.C.A. § 5103A(d) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c)(4) (2012). Regarding the Veteran's claim for service connection for coronary artery disease and hypertensive heart disease, there has not yet been a medical inquiry into whether these conditions are attributable to the underlying adjudicated service-connected lumbar spine disability (including as a consequence of the 1999 post-operative complications following back surgery, with attendant renal dysfunction and hypertension). An examination to resolve this question is warranted. Moreover, as to the claim for service connection for spinal osteomyelitis, whereas the Veteran clearly had this condition immediately following back surgery in 1999, it is not clear whether there have been any recurrences. An orthopedic examination is thus needed to address this additional issue. The claims file further reflects that the Veteran has been awarded disability benefits from the Social Security Administration (SSA), and that the basis for this award involved many of the same conditions now claimed for VA compensation purposes. Therefore, the records from the SSA proceedings would be relevant to the instant appeal. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). Consequently, this case must be remanded to acquire the SSA administrative decision on the claim for benefits from that agency and supporting medical records. See Murincsak v. Derwinski, 2 Vet. App. 363 (1992). Any recent VA treatment records should also be obtained. Accordingly, these claims are REMANDED for the following action: 1. Obtain copies of the SSA administrative decision on a claim for benefits with that agency, along with all medical records underlying that determination. Then associate all documents received with the claims file. 2. Make arrangements to obtain the Veteran's complete VA treatment records, dated since December 2008. 3. Thereafter, schedule the Veteran for a VA cardiovascular examination. The claims folder must be provided to and reviewed by the examiner in conjunction with the requested VA examination. All indicated tests and studies should be performed, and all findings should be set forth in detail. The VA examiner is requested to indicate whether it is at least as likely as not (50 percent or greater probability) that the Veteran's coronary artery disease and hypertensive heart disease, status post myocardial infarction and bypass surgery, are (a) proximately due to or the result of, or (b) aggravated by, his service-connected degenerative disc disease of the lumbar spine, renal disease, and/or hypertension. The examiner should include in the examination report the rationale for any opinion expressed. However, if the examiner cannot respond to the inquiry without resort to speculation, he or she should so state, and further explain why it is not feasible to provide a medical opinion. 4. Schedule the Veteran for a VA orthopedic examination regarding his claimed spinal osteomyelitis. The claims folder must be provided to and reviewed by the examiner in conjunction with the requested VA examination. All indicated tests and studies should be performed, and all findings should be set forth in detail. The VA examiner is first requested to indicate whether the Veteran currently has, or has manifested at any time since March 2008 (when he filed the instant claim), spinal osteomyelitis or residuals thereof. Provided this is verified to have been the case, please then indicate whether this is related to the 1999 lower back surgery and subsequent post-operative complications/infection. The examiner should include in the examination report the rationale for any opinion expressed. However, if the examiner cannot respond to the inquiry without resort to speculation, he or she should so state, and further explain why it is not feasible to provide a medical opinion. 5. Next, review the claims file. If any of the directives specified in this remand have not been implemented, appropriate corrective action should be undertaken before readjudication. Stegall v. West, 11 Vet. App. 268 (1998). 6. Finally, readjudicate the claims on appeal, based upon all additional evidence received. If the benefits sought on appeal are not granted, the Veteran and his attorney should be furnished with a Supplemental Statement of the Case (SSOC) and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claims, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655. These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs