Citation Nr: 1322826 Decision Date: 07/17/13 Archive Date: 07/24/13 DOCKET NO. 05-15 968 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a cervical spine disability, also claimed as muscle spasm, bursitis and arthritis of the shoulder and neck, to include as secondary to service-connected lumbosacral strain. 2. Entitlement to service connection for a thoracic spine disability, to include as secondary to service-connected lumbosacral strain. 3. Entitlement to a rating greater than 20 percent for lumbosacral strain. 4. Entitlement to an initial rating greater than 10 percent for radiculopathy to the right lower extremity. 5. Entitlement to an initial rating greater than 10 percent for radiculopathy to the left lower extremity. 6. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance. REPRESENTATION Appellant represented by: Tennessee Department of Veterans' Affairs ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran served on active duty from October 1969 to October 1973. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which denied entitlement to an evaluation in excess of 20 percent for lumbosacral strain; awarded service connection for radiculopathy of the right and left lower extremities, each evaluated at 10 percent disabling; denied entitlement to SMC based on the need for aid and attendance; denied service connection for edema in the legs; and reopened claims for service connection for cervical and dorsal (or thoracic) spine disorders and denied these claims on a de novo basis. The Board remanded the case to the RO via the Appeals Management Center (AMC) in Washington, DC, for further development in January 2008 and September 2010. In August 2012, the Board denied service connection for edema of the bilateral lower extremities, but found that new and material evidence had been submitted sufficient to reopen the claims for service connection for a cervical spine disorder and a thoracic spine disorder. The reopened claims for service connection, as well as the claim for an increased rating for lumbosacral strain, the claims for higher initial ratings for radiculopathy of the right and left lower extremities, and the claim for SMC were remanded for additional development. After completing additional development, the AMC continued to deny the claims (as reflected in a February 2013 supplemental statement of the case (SSOC)), and returned these matters to the Board. In her April 2004 notice of disagreement (NOD), the Veteran stated that she wished to apply for RH/service-connected life insurance and requested an application. It does not appear that this matter has been addressed. The issue of entitlement to Service Disabled Veterans' Insurance/RH has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over this matter, and it is referred to the AOJ for appropriate action. 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 Board sincerely regrets the additional delay that inevitably will result from this additional remand, but it is necessary to ensure there is a complete record and so the Veteran is afforded every possible consideration. The record reflects that there is outstanding evidence which is potentially pertinent to the appeal. The Veteran underwent spine surgery (laminectomy at the T12-L1 level) in November 2004, performed by a private neurosurgeon, Dr. H., of Appalachian Neurosurgical Clinic. In January 2008, the Board remanded the case, in part, to obtain treatment records from this facility. In a January 2008 letter, the AMC asked the Veteran to complete and return a VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs (VA), so that VA could obtain her treatment information from Appalachian Neurosurgical Clinic. The Veteran did not subsequently return a release regarding these records. VA is only obligated to obtain records that are adequately identified and for which necessary releases have been received. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Normally, when a Veteran does not provide a release form for private treatment records; it is not possible for VA to obtain them. However, VA treatment records document that, in October 2004, the Veteran was referred to Dr. H., an outside neurosurgeon. Surgery to excise a spinal cord tumor was scheduled for November 2004. VA records indicate that a pathology report revealed that the L1 spinal cord tumor was meningioma with ossification and the Veteran was scheduled for follow-up with Appalachian Neurosurgical Clinic in March 2005 with additional neurosurgical follow-up in May 2005. A May 2005 VA note entitled "Outside Fee Other Procedure Report" indicates that a neurosurgery report had been received from an outside source and scanned into the Veteran's computerized medical record, and could be viewed in the Veterans Health Information Systems and Technology Architecture (VISTA) imaging. Another "Outside Fee Other Procedure Report" note dated in August 2005 indicates that another neurosurgery report is available in VISTA imaging. A July 2007 VA treatment record indicates that the Veteran was followed by Dr. H. for back pain. An August 2007 treatment record indicates that an outside neurological report was available in VISTA. A November 2007 VA note entitled "Fee Scanned Report" indicates that a scanned report available in VISTA imaging indicated that Dr. H. was ordering a cervical epidural steroid. A June 2008 VA treatment record states that the Veteran was due to see neurosurgery through fee-basis later that month. A "Fee Scanned Report" from the same month indicates that a report from Appalachian Neurosurgical Clinic was available in VISTA imaging. Similarly, VA treatment records refer to "Fee Scanned Reports" from another physician, Dr. D. A September 2008 VA treatment note indicates that the Veteran saw Dr. D., a rheumatologist, for generalized aches and pains. Dr. D. reportedly told the Veteran that she had osteoarthritis, osteoporosis, and fibromyalgia. Treatment records from Appalachian Neurosurgical Clinic, Dr. H., and Dr. D. are not presently of record. While the Veteran has not submitted releases to enable VA to obtain these private treatment records, the above VA treatment records indicate that VA is in possession of at least some records from these healthcare providers in that they have been scanned into VISTA imaging. Accordingly, the AMC/RO should attempt to obtain these records and associate them with the claims file. See 38 C.F.R. § 3.159(c)(2); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). VA also has a duty to obtain relevant records of treatment reported by private physicians. Massey v. Brown, 7 Vet. App. 204 (1994). An August 2007 VA treatment record indicates that the Veteran received chiropractic treatment outside of VA without much help for her generalized myalgia with spasms in the neck area. An April 2008 VA treatment record identifies the Veteran's private chiropractor as Dr. J. Records of this chiropractic treatment are not currently available for the Board's review. The AMC/RO should also attempt to obtain these records on remand. Additionally, at the time of the Board's January 2008 remand, the most recent VA treatment records associated with the claims file were dated in August 2005. The Board instructed that any additional VA outpatient treatment records, dated since August 2005, should be obtained on remand. In a January 2008 letter, the AMC advised the Veteran that her treatment records from the Mountain Home VA Medical Center (VAMC), dated from December 12, 2005 to January 29, 2008, had been received. However, while VA imaging reports dated from December 2005 to January 2008 were obtained, the progress notes obtained are dated from June 2007 to January 2008. There are no VA treatment records (other than a June 2006 colonoscopy operative report) dated between August 2005 and June 2007 presently available for the Board's review. Significantly, in a June 2008 letter, the Veteran's VA physician stated that she had had been treating the Veteran since October 2006. The June 2008 letter indicates that additional VA treatment records, dated between August 2005 and June 2007, are available. As any outstanding records of VA treatment are potentially pertinent to the appeal and within the control of VA, they should be obtained and associated with the claims file. Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell, 2 Vet. App. at 613. Further, the most recent VA treatment records currently available for the Board's review are dated in September 2012. A November 2012 VA examination report refers to an MRI of the lumbar spine obtained at the Augusta VAMC earlier that month. On remand, the AMC/RO should obtain any more recent VA treatment records. The Board further notes that, in her April 2004 NOD, the Veteran stated that she was enclosing her application for vocational rehabilitation. No VA vocational rehabilitation folder has been forwarded to the Board. On remand, the AMC/RO should associate with the claims file the Veteran's vocational rehabilitation records or folder. See Dunn, 11 Vet. App. at 466-67; Bell, 2 Vet. App. at 613. The record indicates that the Veteran was a federal employee from 1996 to 2008. A December 2008 VA treatment record notes that the Veteran had been approved for disability retirement, and she signed a release so her physician could contact the Office of Personnel Management (OPM) on her behalf. Despite the foregoing, records regarding a claim for Federal disability retirement have not been requested from OPM. Thus, the Board finds that the AMC/RO should obtain and associate with the claims file a copy of any decision from OPM regarding the claim for Federal disability retirement pertinent to the claims on appeal. See 38 C.F.R. § 3.159(c)(2). The Board also finds that an additional VA examination is warranted. The case was previously remanded, in August 2012, to obtain a VA examination and medical opinion regarding the claims on appeal. In the August 2012 remand, the Board stated that the Veteran had been diagnosed with several lumbosacral spine disorders, including (1) chronic low back pain, (2) lumbosacral strain, (3) intervertebral disc syndrome, (4) bulging discs at L3 or L4 through S1, (5) hypertrophic arthroplasty of articular facets at L4-L5 with narrowing of the neuroforamen, (6) paravertebral muscle spasms over the entire back with a trigger point over the right trapezius muscle, (7) bilateral sacroiliitis, (8) mild degenerative disc disease of the lumbar spine, (9) status post laminectomies at the T12-L1 level, and (10) myelopathy. The Board instructed that the VA examiner should determine which, if any of the listed diagnoses were attributable to the Veteran's service connected lumbosacral strain, or were otherwise related to her military service, including the 1970 injury that marked the onset of her service-connected lumbosacral strain. With regard to any lower back disorders that were not found to be encompassed by the Veteran's service-connected lumbosacral strain, the examiner was asked to provide an opinion as to (i) whether it is at least as likely as not that any differentiated lumbar spine disorders had their clinical onset during active service or were otherwise related to any in-service disease, event, or injury, to include the Veteran's in-service back injuries and reports of back pain, and (ii) whether it was at least as likely as not that any differentiated lumbar spine disorder was (a) proximately due to, (b) the result of, or (c) aggravated by the Veteran's service-connected lumbar spine disability, currently diagnosed as lumbosacral strain, or her service-connected radiculopathy of the bilateral lower extremities The VA examiner was further asked to state whether the findings reported in a March 2012 VA examination report (which includes a diagnosis of degenerative arthritis of the lumbar spine, with myelopathy, and notes mild functional impairment due to lumbosacral strain and symptoms of radiculopathy) were attributable to the Veteran's service-connected lower back disability and radiculopathy of the lower extremities. If necessary, the examiner was to perform an additional examination in order to determine the severity of the Veteran's service-connected back disability. Further, in light of evidence of diagnosed disorders of the cervical and thoracic spine, the examiner was asked to provide an opinion as to the diagnosis, date of onset, and etiology of any cervical or thoracic spine disorder found to be present. Specifically, the examiner was to provide an opinion as to whether it was at least as likely as not that any diagnosed cervical or thoracic spine disorder had its clinical onset during active service or was otherwise related to any in-service disease, event, or injury, to include the Veteran's in-service back injuries and reports of back pain. The examiner was also to determine whether it is at least as likely as not that any diagnosed cervical or thoracic spine disorder was (a) proximately due to, (b) the result of, or (c) aggravated by her service-connected lumbar spine disability and bilateral radiculopathy of the lower extremities. The Veteran was afforded a VA spine examination in November 2012. The examiner, a neurosurgeon, indicated that the first complaint of neck pain he found was in 2008, but commented that a 2007 MRI showed degenerative disc disease (DDD) of the cervical spine. The examiner stated that he was unable to objectively test lumbar range of motion as the Veteran could/would not move at all due to pain. Neurological examination revealed normal strength in all motor groups, normal tone, mass, reflexes, and sensation to light touch. The assessment was chronic musculoskeletal low back pain without any neurological deficits, consistent with the essentially normal lumbar spine MRI, and chronic diffuse, non-specific pain consistent with fibromyalgia, not with lumbar or thoracic or cervical spine disease. The examiner opined that, "At best, the Veteran is entitled to the current service connected disability for lumbar strain." He added that, "Certainly, a lumbar strain will not directly cause any other spinal problems." He added that the Veteran did not have any clinical radiculopathy or myelopathy nor did she have lumbar disc disease. Rather, she had mild arthropathy of the facet joints which was found many years after separation from service. The examiner opined that the Veteran, "should not be entitled to anything for sciatic inflammation" commenting that a lumbar strain would not directly cause a sciatic problem. He added that the Veteran's leg numbness, which had been called radiculopathy and sciatica, was neither. Rather, she had subjective anterior thigh numbness which first started before her thoracic meningioma was discovered. The examiner stated that the Veteran's description of her numbness was akin to a peripheral neuropathy such as meralgia paresthetica which is often seen in patients who are overweight, as the Veteran was prior to gastric bypass surgery. He concluded by stating that the "sciatic inflammation" was "most definitely not a service connected disability." Regarding the cervical spine, he opined, "She currently has a degree of cervicalgia or chronic musculoskeletal neck pain and some degenerative cervical disc disease but this is not something which started while she was in the military service and it is certainly without any doubt not related to her lumbar strain." Regarding the thoracic spine, he stated that her complaints were best characterized as muscular in nature and were more akin to post-surgical symptoms. The examiner went on to address the diagnoses pointed out in the August 2012 remand. He commented that the Veteran did not have intervertebral disc syndrome of the lumbar spine. While she did have intervertebral disc syndrome of the cervical and thoracic spine, he stated "BUT THESE ARE NOT SERVICE CONNECTED CONDITIONS." He stated that she did not have bulging discs at L3 or L4 through S1, based on a November 2012 MRI report, and such condition would not be service connected even if in existence. Regarding hypertrophic arthroplasty of articular facets at L4-5 with narrowing of the neuroforamen, he stated that the Veteran did have this condition, although it was arthropathy, not arthroplasty; it was only a radiographic diagnosis without clinical correlation in this context; and it was only diagnosed years after the Veteran left the service, thus not service connected. In regard to paravertebral muscle spasms over the entire back, he commented that there were no spasms on examination and such were "irrelevant anyway as there is no correlation between any of these and her chronic lumbar strain/back pain; not service connected." Regarding bilateral sacroiliitis, the examiner stated that the Veteran did not have this condition as there was no clinical or historical evidence nor examination findings to suggest the presence of bilateral sacroiliitis and such condition would not be service-connected even if it was present. He also stated that the status post laminectomy at the T12-L1 level was not service connected. Finally, in regard to myelopathy, the examiner indicated that there was not clinical evidence of this condition and, even if there was, it would not be service connected. The examiner summarized by stating that it was "not likely at all that any of the claimed disorders were service-connected as they did not start while the Veteran was serving in the military, they were not caused by anything that occurred or happened to her while she was in the service and they are not, without any doubt, connected to her lumbar strain which is the only service connected disability this Veteran is fortunate enough to have been granted." Initially, the Board notes that, in her July 2003 claim for service connection, the Veteran indicated that she was seeking service connection for bursitis. She clarified in a July 2003 statement that her bursitis was located in her shoulder. Service treatment records document that, in January 1971, the Veteran presented with left shoulder pain. She reported redness and swelling starting that morning. X-ray and physical examination were negative and she was instructed to apply heat. In January 1973 she received treatment for right shoulder pain. There was tenderness over the right shoulder muscle groups, but no joint tenderness or swelling. The impression was muscle pain. During VA treatment in August 1993, the Veteran complained of pain in the right shoulder blade. The provisional diagnosis was intercostal neuritis/myositis. In December 2003, the Veteran reported muscle spasms in her left neck and shoulder. A March 2004 treatment record includes an assessment of right shoulder bursitis. The November 2012 VA examiner noted moderate point tenderness over the left trapezius area and severe point tenderness over the right shoulder's anterior capsule, moderate on the left. However, he did not render a diagnosis regarding either shoulder. VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, but the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for determining whether the evidence "indicates" that there "may" be a nexus between a current disability and an in-service event, injury, or disease is a low one. McLendon, 20 Vet. App. at 83. In light of the evidence of in-service complaints regarding the shoulders, the March 2004 assessment of right shoulder bursitis, and the reports of pain and tenderness in the shoulders, the Board finds that a new VA examination to obtain a medical opinion regarding whether the Veteran has a shoulder disorder related to service or her service-connected lumbosacral strain is warranted. See McLendon, 20 Vet. App. at 83; see also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the requirement of the existence of a current disability is satisfied when a Veteran has a disability at the time she files her claim for service connection or during the pendency of the claim, even if the disability resolves prior to adjudication of the claim). Additionally, regarding the claimed cervical spine disorder, the November 2012 VA examiner stated that the first complaint of neck pain he found was in 2008. However, there are numerous complaints of neck pain documented in the VA treatment records dated prior to 2008. Specifically, in February 1986, the Veteran described a headache which seemed to be caused by neck pain. She stated that her muscles were tight and reported that her headaches had been worse since her in-service back strain. The diagnosis was chronic low back pain and X-ray of the cervical spine was essentially normal. During VA treatment in May 1994, the Veteran reported trouble with her entire spine since 1970 or 1971. The assessment was complaint of pain in the entire spine with no objective findings. An August 1994 VA consultation request notes that the Veteran had neck pain associated with her back. The Veteran described back, neck, and shoulder pain during treatment in October 1994. The impression was musculoskeletal pain. In April 1995, the Veteran described pain in her back and neck, and commented that part of her pain could be due to the heaviness of her breasts. The Veteran underwent breast reduction surgery in December 1995. In March 1997, the Veteran fell down concrete steps and presented to the Mountain Home VAMC with complaints of pain in the right neck, back, and hip. The impression was cervical dorsal sprain. In April 1997, she complained of cervical pain and reported that her back problem had been corrected following her breast reduction surgery, until a fall one month earlier. The assessment was cervical muscle spasm. The Veteran again complained of neck pain in May 1998. In September 2003, she complained of increased pain in the paraspinal muscles of her neck, with worsened tenderness since physical therapy. The assessment was cervical spine arthralgia and paraspinal muscle spasm. The November 2012 VA examiner also commented that the Veteran was not seen for complaints of neck or thoracic back pain during service. Service treatment records document that in March 1973, the Veteran was seen in the neurology clinic for headaches, which she described as consisting of cervical-frontal pain. She reported that her headaches were heralded by occipital-cervical pain. The impression was tension headaches and common migraine. While the in-service reports of cervical pain appear to be related to the Veteran's headaches (for which service connection has been granted) they, nevertheless, do document in-service cervical pain. The November 2012 VA examiner provided a clear negative opinion regarding the relationship between the Veteran's cervical and thoracic spine disorders and her service-connected lumbosacral strain. He did not, however, clearly address whether the Veteran has a cervical or thoracic spine disorder which was aggravated by her lumbosacral strain. Similarly, while the November 2012 VA examiner clearly provided a negative opinion regarding whether the Veteran is entitled to service connection for various conditions affecting the lumbar spine other than lumbosacral strain, he did not clearly address whether any of these conditions were aggravated by the service-connected lumbosacral strain. The Court has held that where a veteran's service-connected disability causes an increase in, but is not the proximate cause of, a nonservice connected disability, the veteran is entitled to service connection for that incremental increase in severity attributable to the service- connected disability. Allen v. Brown, 7 Vet.App. 439 (1995). Further, despite the VA examiner's statement that the first complaint of leg numbness was in 2003, VA treatment records document complaints of numbness in the legs prior to that time. For example, the Veteran described low back pain radiating into the lower extremities in March 2000, at which time she also reported numbness in the lower extremities. A November 2003 EMG/NCV indicated bilateral S1 radiculopathy. Additionally, the examiner stated that there was no clinical or historical evidence of bilateral sacroiliitis. However, the Veteran has been diagnosed with this condition during the pendency of the appeal, as an August 2004 VA treatment record includes an impression of bilateral sacroiliitis. Because VA undertook to provide a VA examination to evaluate the disorders on appeal, the Board must ensure that such an examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Stefl v. Nicholson, 21 Vet. App. 120 (2007). Accordingly, the Veteran should be scheduled for a new VA examination to obtain a medical opinion regarding the relationship between any disorders of the shoulders, cervical spine, thoracic spine, and lumbar spine (other than lumbosacral strain) and service or the service-connected lumbosacral strain. In rendering this opinion, the examiner should consider any pertinent post-service injuries. In this regard, VA treatment records indicate that, in January 1983, the Veteran fell getting out of the bathtub injuring her low back and right knee. In March 1997, the Veteran fell down concrete steps and presented to the Mountain Home VAMC with complaints of pain in the right neck, back, and hip. The impression was cervical dorsal sprain. A May 1999 physical therapy note indicates that the Veteran slipped in March 1999, irritating her neck and upper back. May 1999 X-ray reports of the cervical and thoracic spines indicate that the Veteran jerked her back and shoulder in her March 1999 fall, and experienced continuing scapular and shoulder pain. An October 2001 record indicates that the Veteran suffered a fall with resultant musculoskeletal injuries. In March 2002, the Veteran reported to her psychiatrist that she pulled a muscle in her back taking care of her son. In June 2008, the Veteran received treatment for a neck sprain/pain after lifting a television. In September 2008, she reported hurting her back pulling weeds in her garden. Additionally, because the Veteran is being afforded another VA examination, the examiner should also evaluate the current severity of the service-connected lumbosacral strain and radiculopathy in the right and left lower extremities. The Board observes that the Veteran filed her current claim for an increased rating in July 2003. During the pendency of the appeal, the criteria for evaluating disabilities of the spine were revised, effective September 26, 2003. 68 Fed. Reg. 51,454 (August 27, 2003). This change revises the spine criteria to "ensure that it uses current medical terminology and unambiguous criteria, and [to ensure] that it reflects medical advances that have occurred since the last review." The revised criteria are found at 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine (2012). Under the rating criteria as in effect prior to September 26, 2003. A 40 percent rating is warranted under Diagnostic Code 5295 when there is severe lumbosacral strain with listing of the whole spine to the opposite side; positive Goldthwaite's sign; marked limitation of forward bending in the standing position; loss of lateral motion with osteoarthritic changes; or narrowing or irregularity of the joint space; or some of the above with abnormal mobility on forced motion. 38 C.F.R. § 4.71a, Diagnostic Code 5295 (2002). The examiner should comment as to whether the Veteran's service-connected lumbosacral strain is manifested by any of these symptoms. Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for her lumbar, cervical, and/or thoracic spine, or for her radiculopathy in the lower extremities. After acquiring this information and obtaining any necessary authorization, obtain and associate any outstanding pertinent records with the claims file or Virtual VA e-folder. A specific request should be made for: (1) treatment records from the Mountain Home VAMC, dated between August 2005 and June 2007; (2) treatment records from the Augusta VAMC, dated since September 2012; (3) any pertinent treatment records from private physicians (including fee-basis records) contained in VISTA imaging (to include records from Appalachian Neurosurgical Clinic, Dr. H., and/or Dr. D., as discussed above); (4) any additional records from Appalachian Neurosurgical Clinic, Dr. H., and/or Dr. D. which are not included in VISTA imaging; and (5) chiropractic records from Dr. J. (as identified during VA treatment in April 2008). If any identified records are not obtainable (or none exist), the Veteran and her representative should be notified and the record clearly documented. 2. Associate with the claims file the Veteran's VA vocational rehabilitation folder. 3. Contact the Office of Personnel Management and attempt to obtain any records regarding the Veteran's claim for Federal disability retirement, pertinent to the claims on appeal. If no records are available, that fact should be documented, in writing, in the record, and the Veteran should be provided notice of that fact. 4. The Veteran should be afforded a VA examination to determine the etiology of any disorders of the shoulders, cervical spine, thoracic spine, and/or lumbar spine (other than lumbosacral strain). All indicated tests and studies are to be performed. In conjunction with the examination, the claims folder must be made available to the examiner for review of the case. A notation to the effect that this record review took place should be included in the report of the examiner. Following examination of the Veteran and a review of the record, the examiner should identify any disorders of the shoulders, cervical spine, thoracic spine, or lumbar spine (other than lumbosacral strain) present at any time since July 2003 (when the Veteran filed her current claim). In regard to each OR any diagnosed condition, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the current condition had its clinical onset during active service or is related to any in-service disease, event, or injury; OR in the alternative, whether it is at least as likely as not (50 percent or greater probability) that the Veteran's condition was caused OR AGGRAVATED by her service-connected lumbosacral strain. The examiner MUST specifically provide etiological opinions regarding the Veteran's diagnosed intervertebral disc syndrome of the cervical and thoracic spines (as documented in the November 2012 VA examination report) as well as right shoulder bursitis (as documented during VA treatment in March 2004). The examiner should also discuss each of the following diagnoses and is advised that service connection may be established for a disability present at the time the Veteran filed her claim (in July 2003) or at any time since, even if the disability has since resolved: (a) Intervertebral disc syndrome, as reported in an October 2003 VA treatment record (b) Bulging discs, as reported in August 2002 and August 2004 MRI reports (c) Hypertrophic arthropathy of articular facets at L4-L5 with narrowing of the neuroforamen, as reported on VA examination in October 2003 (d) Paravertebral muscle spasms over the entire back with a trigger point over the right trapezius muscle, as reported during VA treatment in August 2004. (e) Bilateral sacroiliitis, as reported during VA treatment in August 2004 (f) Degenerative disc disease of the lumbar spine, as reported in a July 2003 VA treatment record and on VA examination in August 2004 (g) Status post laminectomy at T12-L1 level, as reported on VA examination in September 2009 (h) Myelopathy, as reported during VA treatment in May 2003 In rendering the requested opinion, the examiner should specifically consider the in-service complaints of cervical pain (as documented in March 1973) and shoulder pain (as documented in January 1971 and January 1973). He or she should also consider post-service complaints of neck pain as early as in February 1986, with additional complaints documented in 1994, 1995, 1997, 1998, and 2003 (discussed above) and post-service complaints of shoulder pain, as documented in August 1993 (discussed above). The examiner should also consider any pertinent post-service injuries, including in January 1983, March 1997, March 1999, October 2001, March 2002, June 2008, and September 2008 (discussed above). The examiner should conduct range of motion testing of the lumbar spine (expressed in degrees). The examiner should render specific findings as to whether, during the examination, there is objective evidence of pain on motion, weakness, excess fatigability, and/or incoordination. If pain on motion is observed, the examiner should indicate the point at which pain begins. In addition, the examiner should indicate whether, and to what extent, the Veteran experiences likely functional loss due to pain and/or any of the other symptoms noted above during flare-ups and/or with repeated use. To the extent possible, the examiner should express any such additional functional loss in terms of additional degrees of limited motion. The examiner should identify any neurological impairment associated with the Veteran's service-connected lumbosacral strain. In identifying any such impairment, the examiner must consider and address the opinion of the November 2012 VA examiner (including his statement that the Veteran's reported leg numbness is neither sciatica nor radiculopathy). If any neurological impairment is found to be associated with the Veteran's service-connected lumbosacral strain, the examiner should provide an assessment of the severity of each such manifestation (as mild, moderate, moderately severe, or severe). The examiner should also state whether there is any listing of the whole spine to the opposite side; positive Goldthwaite's sign; marked limitation of forward bending in the standing position; loss of lateral motion with osteoarthritic changes; narrowing or irregularity of the joint space; or abnormal mobility on forced motion. The examiner should comment as to whether it is possible to distinguish the symptoms and effects of the service-connected lumbosacral strain from those attributable to any other disorder affecting the lumbar spine which is not service-connected. If it is not medically possible to do so, the examiner should clearly so state, indicating that the above-noted findings are indicative of the Veteran's overall impairment associated with her service-connected lumbosacral strain. All examination findings, along with the complete explanation for all opinions expressed, should be set forth in the examination report. 5. Next, review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action must be implemented. If the examination report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 6. Finally, after completing the requested actions, and any additional notification and/or development deemed warranted, readjudicate the claims on appeal in light of all pertinent evidence and legal authority. If the benefit sought on appeal remains denied, furnish to the Veteran and her representative an appropriate SSOC that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matters that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). 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 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).