Citation Nr: 1331291 Decision Date: 09/27/13 Archive Date: 10/01/13 DOCKET NO. 07-28 179 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to an acquired psychiatric disorder other than PTSD. 3. Entitlement to service connection for a stomach disorder (claimed as ulcers). 4. Entitlement to service connection for headaches. 5. Entitlement to service connection for erectile dysfunction. 6. Entitlement to an increased rating greater than 20 percent for butterfly hemivertebra T6 with dorsal kyphosis. WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel INTRODUCTION The Veteran had active service from November 1973 to November 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2005 rating decision of the RO in Montgomery, Alabama, which increased the Veteran's rating for butterfly hemivertebra T6 to 20 percent disabling, declined to reopen the stomach condition service connection claim and otherwise denied service connection for headaches, erectile dysfunction, and PTSD. The Board remanded this case in March 2011 to provide the Veteran with a hearing before the Board. The Veteran testified before the undersigned at a March 2012 videoconference hearing. A transcript has been associated with the file. In an August 2012 determination, the Board reopened the claim for entitlement to service connection for a stomach condition (claimed as ulcers) and remanded all the claims for additional development. The matter again is before the Board. As noted in passing in the August 2012 Board determination, the initial claim of entitlement to service connection for PTSD encompassed a claim for entitlement to service connection for an acquired psychiatric disorder other than PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). As will be discussed in greater detail below, the evidence of record is sufficient to deny the Veteran's PTSD claim; however, additional evidence is required prior to a determination as to the relationship of the other diagnosed acquired psychiatric disorders to his military service. As such, the issue has been bifurcated and listed as above. The Board has not only reviewed the Veteran's physical claims file, but also his Virtual VA electronic claims file to ensure a total review of the evidence. As discussed in the August 2012 Board remand, the Veteran also has filed additional service connection claims, including for traumatic brain injury (TBI), back injury, neck injury, and left leg injury in 2011. The back and left leg claims have previously been denied. The RO has not yet adjudicated these issues. The Board REFERS the issues of service connection for TBI and a neck injury and the petitions to reopen claims for back and left leg disabilities to the RO for appropriate action. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). All claims except for the PTSD claim are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran did not engage in combat or claim a stressor related to fear of hostile military or terrorist activity consistent with the places, types, and circumstances of his service, and there is no corroboration or verification of the occurrence of the Veteran's claimed in-service stressor. 2. The Veteran's PTSD has not been medically attributed to any verified in-service stressful incident. CONCLUSION OF LAW PTSD was not incurred in service and is not otherwise related to service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) The VA has met all statutory and regulatory notice and duty to assist provisions. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his or her possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. VCAA letters dated in October 2004 and September 2012 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2013); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claim. The letters informed him that additional information or evidence was needed to support his claim, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. The September 2012 letter also explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). As noted above, the Veteran also was afforded a hearing before the undersigned Acting Veterans Law Judge (AVLJ) during which he presented oral argument in support of his claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ/AVLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the AVLJ fully explained the issues on appeal during the hearing and specifically discussed the basis of the prior determination, the element(s) of the claim that were lacking to substantiate the claim for benefits, and suggested the submission of evidence that would be beneficial to the Veteran's claim. Indeed, based on the evidence elicited at the March 2012 Board hearing, the Veteran's claim was remanded for additional development. Significantly, the Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant, the AVLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA treatment records are in the file. In addition, a request for records was made to the Social Security Administration (SSA), but in September 2012 SSA indicated that no records were available. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran has not otherwise identified any records not associated with the claims file that he believes would be helpful to his claims. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. See 38 C.F.R. § 3.159(c)(4). As to the Veteran's PTSD claim, the Board concludes that an examination is not needed. VA has a duty to provide a VA examination when the record lacks evidence to decide the Veteran's claim, and there is evidence of: (1) a current disability; (2) an in-service event, injury, or disease; and (3) some indication that the claimed disability may be associated with the established event, injury, or disease. See 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). As will be discussed in greater detail below with respect to the PTSD claim, the Board believes that there is no credible evidence that his claimed in-service stressor occurred as he described. A further remand for a VA examination on that particular claim would accordingly be futile. Based on the September 2012 notice letter, the October 2012 VA examination report, the request to and September 2012 response from SSA, the association of VA treatment records, and the subsequent readjudication of the claim, the Board finds that there has been substantial compliance with its August 2012 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2012). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2013). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection for PTSD specifically requires medical evidence establishing a diagnosis of the disability, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between the current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304(f) (2013). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(f)(1) (2013); see also, 38 U.S.C.A. § 1154(b) (West 2002 & Supp. 2012). Similarly, if a stressor claimed by a veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of posttraumatic stress disorder and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(f)(3). Otherwise, the law requires corroboration of a claimed stressor. Where a determination is made that the Veteran did not "engage in combat with the enemy," or the claimed stressor is unrelated to combat, the Veteran's lay testimony alone will not be enough to establish the occurrence of the alleged stressor. See Moreau v. Brown, 9 Vet. App. 389, 395 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). In such cases, the record must include service records or other credible evidence that supports and does not contradict the Veteran's testimony. Doran v. Brown, 6 Vet. App. 283, 289 (1994). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. See Moreau, 9 Vet. App. at 395-396; Cohen v. Brown, 10 Vet. App. 128, 42 (1997). The Veteran contends that he has PTSD as the result of a motor vehicle accident in which a truck in which he was riding flipped over and went over the side of a cliff. During this incident, he claims that a fellow service member had his head "blown open" and that the Veteran was thrown 20 feet from the vehicle, injuring his head, neck, and back. The Veteran has claimed that he was paralyzed for multiple months as a result of this incident and hospitalized for 9 months. While the Board notes that early VA treatment records included diagnoses of rule out PTSD, more recent treatment records have included diagnoses of PTSD. In addition, the Board recognizes that a May 2004 letter from the Veteran's private treating physician included a diagnosis of PTSD, as do several private treatment records. As such, the Board will concede that the Veteran has a diagnosis of PTSD. In addition, recent VA treatment records have attributed the Veteran's PTSD in whole or in part to the claimed in-service motor vehicle accident. That said, a March 2007 VA treatment record also included the Veteran's report that he was receiving SSA disability benefits for PTSD after he was robbed twice while working as a retail store clerk. As such, the crucial inquiry is this matter is whether the Veteran has established an in-service stressor and a medical link between the in-service stressor and the Veteran's current PTSD. The Board concludes that he has not. Even assuming a diagnosis of PTSD, the preponderance of the evidence is against a finding that the Veteran engaged in combat with the enemy during active service or that he has attributed any stressors to fear of hostile military or terrorist activity consistent with the places, types, and circumstances of his service, and the Board concludes that his representations regarding a motor vehicle accident involving a truck flipping and going over a cliff, with resulting injury to himself and other service members, to be less than credible. In that regard, the Board must assess the credibility and weight of all the evidence, including the medical evidence. "Just because a physician or other health professional accepted appellant's description of his Vietnam experiences as credible and diagnosed appellant as suffering from PTSD does not mean the [Board is] required to grant service connection for PTSD." Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). The Board is not required to accept a Veteran's uncorroborated account of his active service experiences. See Swann v. Brown, 5 Vet. App. 229, 233 (1993); Wood v. Derwinski, 1 Vet. App. 190, 192 (1991). The Veteran's DD 214 confirms that his sole overseas service was in Germany in 1975 and 1976. Thus, the Board concludes the Veteran did not engage in combat. Furthermore, the Veteran's reported stressor is unrelated to fear of hostile military or terrorist activity, as the incident involved a purported training accident involving a truck flipping and going over the side of a cliff. Therefore, there must be credible supporting evidence of record that the alleged stressor actually occurred in order to warrant service connection. In this case, the contemporaneous evidence of record does not support the Veteran's claim of being involved in an incident during training where a truck flipped over and went over the side of a cliff, with the Veteran being thrown 20 feet from the vehicle and incurring injuries to the head, neck, and back with paralysis for several months. Instead, the Veteran's service treatment records indicate that in January 1976 he was seen for a burning pain in the back that was worse with lifting. At that time, the Veteran explicitly denied any injury to the back. The pain had been present for the previous month. Over the next several weeks, the Veteran underwent weekly follow-up examinations. A March 1976 record stated that the Veteran had had no problems until one to two months previously, as which time he noticed burning pain inferior to the left scapula. Multiple testings showed a congenital butterfly vertebral body at T6 and abrupt short segment kyphosis. An undated treatment record indicated that the Veteran had been evacuated to the United States for evaluation of a thoracic spine abnormality. (The Veteran's personnel records indicate that the evacuation from Germany to the United States occurred in April 1976.) The record stated that the Veteran had been in excellent health until about six weeks previously when he had an episode of burning in the left posterior chest wall. A June 1976 record discussed the Veteran's history of low back problems that had started about six weeks previously with a burning in the left posterior chest wall. Again, the records indicated that the Veteran had no history of previous operations or serious injuries. An August 1976 psychiatric assessment suggested that, "The clinical configuration was similar to that obtained by individuals evidencing signs of neurological dysfunction which is generally seen as posttraumatic syndromes." That same day, however, another record observed that the Veteran had no psychiatric disorder other than secondary symptoms of situational depression due to chronic low back pain, which resulted in restless sleep with accompanying lethargy. The Veteran's history included the onset of low back pain nine months previously that began suddenly. The Veteran denied situational stress, but did report a situational factor involving his father who had been involved in an automobile accident in March 1975. The Veteran stated that he liked working in Germany and was depressed that his discharge would "follow me and influence the jobs I can get." In September 1976, the Veteran went before the Medical Evaluation Board, at which time the Veteran was noted to have been diagnosed with a congenital malformation of the thoracic region and kyphosis in the upper dorsal region. There was no mention of a truck accident or prior injury to the spine. Based on the foregoing contemporaneous medical evidence and lay statements that show no evidence of a serious injury due to a training accident involving a truck flipping over and going over a cliff with resulting injury and paralysis, the Board finds the Veteran's current representations to be highly suspect. In short, the Board gives greater credence and weight to the contemporaneous medical records, including the Veteran's lay statements, than to the recent assertions describing the incidents surrounding the onset of his low back problems and subsequent hospitalization and separation from service. Regardless of whether the Veteran is purposely mischaracterizing the events in service and thereafter or unintentionally doing so, the ultimate conclusion is that his statements are simply not credible evidence. As discussed above, there are objective documents and the Veteran's own statements that refute his claim of sustaining serious injuries as a result of a training accident involving a truck flipping over and going over the side of a cliff that resulted in the Veteran being thrown 20 feet from the vehicle and incurring head, neck, and back injuries that required nine months of hospitalization followed by separation from service, which renders his current representations as to such an incident less than credible. The sole evidence of a motor vehicle accident in his service treatment records is a report of the Veteran's father having been in a motor vehicle accident in 1975. The Board finds it stretches the bounds of credulity to believe that in August 1976 the Veteran would discuss a stressor involving a motor vehicle accident involving his father in 1975, but fail to describe a truck accident involving himself in 1976 that resulted in injuries to multiple fellow service members and the Veteran, including witnessing the death of another service member. See Madden v. Brown, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has "the authority to discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence"). Because of the inconsistency, the Board finds that the Veteran's allegations have no probative value. In short, there is no independent verification of the Veteran's stressors and, indeed, the contemporaneous lay and medical evidence run strongly counter to the existence of the Veteran's current claimed stressor as he has described it. Furthermore, given that the Board has found the Veteran's report of his in-service stressor not credible, the Board further concludes that any diagnosis of PTSD rendered on the basis of such report is also not credible. Accordingly, the claim is denied, as the preponderance of the evidence is against a finding that the Veteran has PTSD as a consequence of an in-service training accident involving a truck overturning and going over the side of the cliff, causing the Veteran to be thrown 20 feet from the vehicle and incur serious head, neck, and back injuries and temporary paralysis. There is no benefit of the doubt that could be resolved in favor of the Veteran. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). ORDER Entitlement to service connection for PTSD is denied. REMAND Psychiatric Disorder other than PTSD In this case, the Veteran has not been afforded a VA examination for his psychiatric disorder claim. The Board concludes that a VA examination is necessary prior to the adjudication of the claim. Specifically, the Veteran is service connected for a thoracic spine disability, and VA treatment records include diagnoses of anxiety disorder not otherwise specified and depression not otherwise specified. During service, an August 1976 service treatment record observed that the Veteran had no psychiatric disorder other than secondary symptoms of situational depression due to chronic low back pain, which resulted in restless sleep with accompanying lethargy. The Veteran's history included the onset of low back pain nine months previously that began suddenly. The Veteran denied situational stress, but did report a situational factor involving his father who had been involved in an automobile accident in March 1975. During a September 1996 VA mental health examination, the Veteran reported feeling depressed and somewhat helpless due to an inability to find a job or do many of the things he enjoyed due to his physical problems, to include his thoracic spine disability. The Veteran's current contentions include the claim that his psychiatric problems are secondary to his service-connected thoracic spine disability. In light of the foregoing, the Board concludes that a VA examination is necessary to consider whether any current psychiatric disability other than PTSD was incurred in or is otherwise related to the Veteran's military service or service-connected disability. Headaches, a Stomach Disorder, and Erectile Dysfunction The Board notes that a September 2011 VA treatment record includes the Veteran's reports that he had been experiencing daily headaches following the prescription of Celexa for his depression. Thus, the evidence of record raises the possibility that any current headache disability was caused or aggravated by the Veteran's depression or other psychiatric disorder. As such, consideration of the Veteran's claim of entitlement to service connection for a headache disability remains deferred pending resolution of the Veteran's claim for service connection for an acquired psychiatric disorder other than PTSD, as the headache claim is inextricably intertwined with this claim. Similarly, the Veteran has asserted that his stomach problems may have been precipitated by his psychiatric problems and that his erectile dysfunction may be caused or aggravated by medication prescribed for depression. The Board accordingly finds these claims to be inextricably intertwined with the claim for service connection for a psychiatric disorder other than PTSD, and they must be included in the remand. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180 (1991). Thoracic Spine Disability As to the increased rating for the Veteran's thoracic spine disability, the last VA examination of the Veteran's spine was in June 2011. While the Board notes that the examination was primarily for the Veteran's claim for entitlement to service connection for a separate lumbar spine disability, the examiner included examination of the thoracic spine. In relevant part, the examination report found thoracolumbar range of motion to include forward flexion of up to 20 degrees, extension to 11 degrees, and bilateral lateral flexion to 11 degrees, and bilateral lateral rotation to 15 degrees. There was a notation that range of motion was limited by pain; however, the report did not state at what point or degree of the arc of motion the Veteran's pain began. In addition, the examiner indicated that lack of effort also may have influenced the limited motion, as the Veteran demonstrated "better movement when putting on articles of clothing after examination." In addition, a May 2011 VA treatment record indicated that the Veteran's forward flexion of the thoracolumbar spine was limited by 50 percent, whereas a July 2011 VA treatment record stated that forward flexion was limited by 80 percent. Thus, there is some suggestion that the Veteran's low back disability may have worsened since the last VA examination of record. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). In order to fully evaluate the Veteran's disability, the Board finds that an additional examination, to include range of motion testing with indication of the objective point of pain onset, is necessary. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). Expedited handling is requested.) 1. Obtain all medical records from all applicable VA medical facilities from September 2012 to the present. Any negative responses should be documented in the file and the Veteran must be provided with an opportunity to provide such medical records. 2. Then, schedule the Veteran for appropriate VA examination for psychiatric disorders other than PTSD. The claims file (including Virtual VA and VBMS records) should be provided to the appropriate examiner for review, and the examiner should note that it has been reviewed. After reviewing the file, obtaining a history directly from the Veteran, and conducting a thorough examination, as well as any studies deemed necessary, the examiner should offer an opinion as to whether any diagnosed psychiatric disability other than PTSD at least as likely as not (1) had its onset during military service or is otherwise related to service OR (2) was caused or permanently aggravated by a service-connected disability, to include his thoracic spine disability. As discussed in the discussion regarding entitlement to service connection for PTSD above, the examiner should not consider credible the Veteran's reports of being involved in a training accident wherein his truck purportedly flipped over and went over a cliff, during which he claimed to have been thrown 20 feet and incurred head, neck, and back injuries and temporary paralysis. That said, please specifically consider, and discuss as necessary, the service treatment records documenting an aggravation of his congenital thoracic spine disability (for which he is separately service connected), the August 1976 service treatment record indicating that the Veteran symptoms of situational depression secondary to chronic low back pain, and the September 1996 VA mental health examination during which the Veteran's depression symptoms were attributed to his inability to work or do many of the activities he enjoyed due to physical problems, including his thoracic spine. The examiner should provide a complete explanation for any opinion provided. 3. Schedule the Veteran for an appropriate VA spine examination, to include a complete physical examination, in order to determine the current severity of his service-connected thoracic spine disability. All tests deemed necessary should be conducted, and all clinical findings should be reported in detail. The complete claims file (including Virtual VA and VBMS records) must be provided to the examiner for review in conjunction with the examination, and the examiner should note that it has been reviewed. The examiner should discuss all symptoms and findings necessary to adequately rate the Veteran under the appropriate diagnostic code(s), specifically at what point during the Veteran's range of motion there is objective evidence of pain onset, if any. All opinions must be supported by a complete rationale. 4. After the above is complete, readjudicate the Veteran's claims (also including the inextricably intertwined claims for service connection for headaches, a stomach disorder, and erectile dysfunction). If a complete grant of all benefits requested is not granted, issue a supplemental statement of the case (SSOC) to the Veteran, and he should be given an opportunity to respond, before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on this matter. 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). ______________________________________________ A. C. MACKENZIE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs