Citation Nr: 1307970 Decision Date: 03/11/13 Archive Date: 03/20/13 DOCKET NO. 09-42 584 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for intervertebral disc syndrome of the cervical spine (cervical spine disability). 2. Entitlement to service connection for intervertebral disc syndrome of the lumbar spine (lumbar spine disability). REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD J. Juliano, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1979 to August 1981. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of the Department of Veterans Affairs (VA) regional office (RO) located in Roanoke, Virginia. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran served on active duty from July 1979 to August 1981. He claims that he incurred cervical spine and lumbar spine disabilities in service. Specifically, he asserts that he fell from a balcony in service and injured his cervical spine and lumbar spine. As an initial matter, the Board acknowledges that the Veteran's service treatment records reflect that in July 1981, the Veteran climbed up to a second story balcony and fell backwards to the ground. Diagnoses of cervical and lumbar strains were recorded. Also, an August 1981 radiological report reflects that the body of C7 was not completely included, and therefore a fracture of C7 could not be ruled out, but that the remainder of the cervical spine as well as the lumbar and thoracic spine were all within normal limits. The Veteran was provided with a VA examination in February 2008, and diagnoses of early intervertebral disc syndrome (IVDS) of the cervical spine and IVDS of the lumbar spine with sciatica were recorded, but no etiological opinion was provided. The Veteran was provided with another VA examination in August 2012. The VA examiner recorded diagnoses including but not limited to IVDS of the cervical spine and lumbar spine. The examiner opined with regard to the Veteran's cervical spine that it was less likely as not related to service, reasoning that the Veteran fell onto his back, not his head, that the x-rays at the time showed no significant abnormalities, and because there was no medical evidence of any cervical complaints for 27 years. As noted above, however, the August 1981 radiological report reflected that a fracture of C7 could not be ruled out. In addition, although the Board acknowledges that the Veteran may not have fallen on his head, he was nevertheless diagnosed with a neck sprain due to the falling accident. In light of all of the above, the Board finds that a remand is necessary so that a VA medical opinion may be obtained to clarify whether the Veteran has a cervical spine disability that is related to service, to include the in-service falling accident, having given consideration to the August 1981 radiological report. A VA medical opinion relating to the Veteran's lumbar spine disability claim should also be obtained for clarification. The Veteran has reported that he was treated at the USAF Hospital in Yokota, Japan for a month after the July 1981 accident. Although a few service treatment records from the Yokota USAF Hospital are in the claims file, there may be several outstanding inpatient treatment records. Therefore, these matters should also be remanded so that any outstanding inpatient treatment records from the Yokota USAF Hospital may be obtained. As a final matter, in his Form 21-526, the Veteran reported having been treated by Drs. Amrein, Thoma, and Martin, but none of these records, or any post-service treatment records, have been associated with the claims file. Based thereon, the Board finds that the Veteran should be provided with one more opportunity to identify any outstanding treatment records for VA to obtain and, to that end, to provide completed Forms 21-4142. Accordingly, the case is REMANDED for the following action: 1. Obtain copies of any inpatient clinical treatment records dated in July/August 1981 pertaining to treatment at the USAF Hospital in Yokota, Japan. All attempts to fulfill this development should be documented in the claims file. If after continued efforts to obtain the records it is concluded that it is reasonably certain they do not exist or further efforts to obtain them would be futile, the AMC must notify the Veteran and (a) identify the specific records the AMC is unable to obtain; (b) briefly explain the efforts that the AMC made to obtain those records; (c) describe any further action to be taken by the AMC with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. If additional records are not obtained, the Veteran should also be provided with notice of alternate sources of evidence that he can submit to supplement the available records. See M21-1MR, Part III, Subpart iii, Chapter 2, Section E.27.b. 2. Provide the Veteran with one more opportunity to identify any outstanding post-service treatment relating to his claimed cervical and lumbar spine disabilities, to include the records of Drs. Amrein, Thoma and Martin. To that end, provide the Veteran with Forms 21-4142. If, after making reasonable efforts to obtain named records the AMC is unable to secure same, the AMC must notify the Veteran and (a) identify the specific records the AMC is unable to obtain; (b) briefly explain the efforts that the AMC made to obtain those records; (c) describe any further action to be taken by the AMC with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 3. After all of the above development has been completed, ask the same VA examiner who prepared the August 2012 VA examination report to review the claims file, including a copy of this remand, and to provide an opinion clarifying whether it is at least as likely as not that any a) cervical spine disability, and b) lumbar spine disability of the Veteran is related to service, including the July 1981 falling accident. The examiner's attention is directed to the August 1981 radiological report showing a C7 fracture could not be excluded. If the examiner who performed the August 2012 VA examination is not available, schedule the Veteran for a new VA examination relating to his cervical and lumbar spine disability claims. The examiner should review the entire record and provide a complete rationale for all opinions offered. A notation to the effect that the claims file was reviewed should be included in the report. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim 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). _________________________________________________ S.S. TOTH Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).