Citation Nr: 1332895 Decision Date: 10/22/13 Archive Date: 10/24/13 DOCKET NO. 09-28 532 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for residuals of a left hand injury. 2. Entitlement to service connection for a low back disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Shamil Patel, Counsel INTRODUCTION The Veteran served on active duty from May 1971 to May 1973. This matter comes 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) in Winston-Salem, North Carolina, which denied service connection for the claimed disabilities. The Veteran's Virtual VA file has also been reviewed as part of his appeal. 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 Unfortunately, additional development is necessary in order to fully and fairly adjudicate the Veteran's claims. First, in a January 2008 statement, the Veteran indicated that he had applied for Social Security Administration (SSA) disability benefits at approximately the same time he filed for VA disability benefits. A review of the claims file does not show that VA attempted to obtain any of the Veteran's SSA records as part of his claims. VA must try and obtain these records before deciding the appeal as part of the duty to assist. See 38 C.F.R. § 3.159(c)(2) and (3) (2013); see also Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010) (as long as a reasonable possibility exists that the SSA records are relevant to a veteran's claim, VA is required to assist a veteran in obtaining the identified records). Second, the Veteran was afforded a VA examination for his claimed disabilities in May 2008. With respect to the Veteran's claim for service connection for a low back disability, the examiner diagnosed degenerative arthritis of the entire spine, but did not offer an opinion as to whether this condition is related to service, including documented complaints of lumbar pain in service. Therefore, a supplemental opinion must be obtained. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). In addition, with respect with the claim for service connection for a left hand disorder, the examiner diagnosed osteoarthritis of the left MP joint, unrelated to an old laceration of the hand. However, he provided no rationale for his opinion. In addition, the Veteran has complained of experiencing pins and needles in his hand. An opinion should be obtained as to whether the Veteran has any current neurological disorder of his left hand, or a scar, as a result of the in-service machete laceration on the palmar surface of his ring and middle fingers in July 1972. Finally, review of the treatment records show that the Veteran reported a history of back surgery. All records related to this surgery should be obtained. Accordingly, the case is REMANDED for the following action: 1. Request from the Social Security Administration all records pertinent to the Veteran's claim for benefits, as well as medical records relied upon concerning that claim. If the search for such records has negative results, the RO/AMC should place a statement to that effect in the Veteran's claims file. 2. Ask the Veteran to identify the medical care provider(s) associated with his prior back surgery. Make arrangements to obtain all records that he adequately identifies. 3. Thereafter, schedule the Veteran for an appropriate VA examination of his left hand. 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 all current disorders of the left hand, to include any neurological disorders, orthopedic disorders, and/or scars. In regard to each 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, to include the in-service machete laceration on the palmar surface of the Veteran's ring and middle fingers in July 1972. All examination findings, along with the complete explanation for all opinions expressed, should be set forth in the examination report. 4. Obtain an opinion from an appropriate VA examiner as to whether the Veteran's currently diagnosed lumbar spine disorder is at least as likely as not (50 percent or greater probability) related to service. The examiner must conduct a review of the claims folder. However, the examiner's attention is called to the following evidence of record: (a) During service in May 1972, the Veteran complained of a 6-day history of midline lower back pain after being struck on the lower back while playing football. The impression was rule out contusion vs. mild low back sprain; (b) During service in June 1972, the Veteran complained of a 2-month history of low back pain. Examination revealed full range of motion with no muscle spasm and questionable tenderness. The impression was a normal back examination, rule out urinary tract infection. (c) After service, a May 1994 MRI revealed eccentric leftward bulging at L4-L5. A June 1994 CT scan revealed a right lateral herniated disc at L5-S1, and a central herniated disc at L4-L5. Subsequently generated imaging tests also reveal disc abnormalities. The May 2008 VA examination diagnosed degenerative arthritis of the entire spine. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current low back disorder had its clinical onset during active service or is related to any in-service disease, event, or injury, to include documented low back pain in service. A complete explanation for all opinions expressed should be set forth in the examination report. 5. Following completion of the foregoing, review the claims folder and ensure that all of the foregoing development has been conducted and completed in full. In particular, determine whether the examiners have responded to all questions posed. If not, the report(s) must be returned for corrective action. 38 C.F.R. § 4.2 (2013). 6. After the requested development has been completed, readjudicate the merits of the Veteran's claims based on all the evidence of record, including any additional information obtained as a result of this remand. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. 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). _________________________________________________ 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) (2013).