Citation Nr: 1335183 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 09-01 414 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 2. Entitlement to an initial evaluation in excess of 20 percent for degenerative disc disease of the lumbar spine with stenosis and disc protrusion. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Shamil Patel, Counsel INTRODUCTION The Veteran served on active duty from August 1974 to June 1981, including service in the Republic of Korea from June 1976 to June 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In that decision, the RO granted service connection for degenerative disc disease of the lumbar spine with stenosis and disc protrusion (low back disability) and assigned a 10 percent rating effective June 22, 2007. The RO also denied service connection for PTSD. Although the Veteran filed a claim for service connection for PTSD, the evidence reflects additional diagnosed psychiatric conditions. Therefore, his claim has been recharacterized to include all potential diagnoses. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a disability claim includes any disability that reasonably may be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). In a February 2011 rating decision, the RO granted a 20 percent rating for the Veteran's low back disability effective from December 1, 2009. A February 2012 rating decision granted a 20 percent rating effective all the way back to June 21, 2007. The Veteran testified at a Travel Board hearing in April 2012 before the undersigned Veterans Law Judge, who was designated by the Chairman to conduct the hearing pursuant to 38 U.S.C.A. § 7107(c), (e)(2) and who is rendering the determination in this case. A transcript of the hearing testimony is in the claims file. The appeal was then remanded by the Board in September 2012 for additional development, and now returns to the Board for further review. The Veteran's Virtual VA file has also been reviewed as part of his appeal. The issue of entitlement to service connection for an acquired psychiatric disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDING OF FACT The Veteran's degenerative disc disease of the lumbar spine with stenosis and disc protrusion is not manifested by forward flexion of 30 degrees or less, ankylosis of the thoracolumbar spine, or incapacitating episodes. CONCLUSION OF LAW The criteria for a rating in excess of 20 percent for degenerative disc disease of the lumbar spine with stenosis and disc protrusion have not been met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. § 3.321, 4.1, 4.2, 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5243 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 A. Duty to Notify Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159 (2013). Such notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). Here, the Veteran is challenging the initial evaluation assigned following the grant of service connection. In Dingess, the U.S. Court of Appeals for Veterans Claims (Court) held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. Moreover, in accordance with 38 U.S.C.A. §§ 5103(a) and 7105(d), the RO properly issued a November 2008 statement of the case (SOC) which contained, in part, the pertinent criteria for establishing a higher rating. See 38 U.S.C.A. § 7105(d)(1). VA complied with the procedural statutory requirements of 38 U.S.C.A. §§ 5104(b) and 7105(d), as well as the regulatory requirements in 38 C.F.R. § 3.103(b). See also Dingess. The Veteran was allowed a meaningful opportunity to participate in the adjudication of the claim. Even though the initial VCAA notice did not address a higher rating, subsequent documentation addressed this matter; there is no prejudice to the claimant. See Overton v. Nicholson, 20 Vet. App. 427 (2006). As noted above, the Veteran also testified at a Board hearing. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) requires that the Decision Review Officer (DRO) or Veterans Law Judge (VLJ) who chairs a hearing must fulfill two duties to comply with the above 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, during the hearing, the VLJ elicited testimony to support the Veteran's claim, and sought to identify any pertinent evidence not currently associated with the claims folder that might substantiate the claim. The Veteran has not asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) or identified any prejudice in the conduct of the hearing. By contrast, the hearing focused on the elements necessary to substantiate the claims and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for benefits. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative demonstrating an awareness of what is necessary to substantiate the claim). As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claims based on the current record. B. Duty to Assist This additional duty includes assistance in obtaining potentially relevant records, such as service treatment records and post-service VA and private medical evaluation and treatment records, as well as the provision of an examination - including for a medical opinion - when necessary to make a decision on the claim. Notably, the claim was previously remanded in August 2012 to obtain any outstanding treatment records, and to provide the Veteran with a VA examination. Here, the Veteran's service treatment records, private treatment records, VA treatment records, lay statements, and hearing transcript have been associated with the claims file. The Veteran was also afforded VA examinations. 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examinations obtained in this case are adequate as they are collectively predicated on a review of the claims file; contain a description of the history of the disabilities at issue; document and consider the relevant medical facts and principles; and record the relevant findings for rating the Veteran's low back disability. VA's duty to assist with respect to obtaining a VA examination or opinion for the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). The directives of the August 2012 remand have been satisfied. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the Board confers on the veteran or other claimant, as a matter of law, the right to compliance with the remand orders). VA has provided the Veteran with the opportunity to submit evidence and argument in support of his claim. The Veteran has not made the Board aware of any additional evidence that needs to be obtained prior to appellate review, and no further action must be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Increased Rating A. Applicable Law Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2013). Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). The Court has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2008). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether the Veteran raised them, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Generally, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). The Court has held that the RO must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) did not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. The Board notes that the guidance provided by the Court in DeLuca must be followed in adjudicating claims where a rating under the diagnostic codes governing limitation of motion should be considered. However, pain that does not result in additional functional loss does not warrant a higher rating. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011) (holding that pain alone does not constitute function loss, but is just one fact to be considered when evaluating functional impairment). The Veteran's low back disability is rated under Diagnostic Code (DC) 5243, which is listed under the General Rating Formula for Diseases and Injuries of the Spine. Lumbar spine disabilities are evaluated under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under § 4.25. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (6) (2012). Under the General Rating Formula, the regulations provide, in pertinent part, for a 20 percent rating when forward flexion of the thoracolumbar spine is greater than 30 degrees, but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted if the medical evidence shows forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted if there is unfavorable ankylosis of the entire spine. These ratings are warranted if the above-mentioned manifestations are present, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. 38 C.F.R. § 4.71a, DCs 5235 to 5243 (2012). The rating criteria under the General Formula for Diseases and Injuries of the Spine also provide the following Notes: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees; extension is zero to 30 degrees; left and right lateral flexion are zero to 30 degrees; and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The combined normal range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of the spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. Neurologic abnormalities are to be rated separated. Diagnostic Code 8520 pertains to paralysis of the sciatic nerve. Under this provision, mild incomplete paralysis warrants a 10 percent disability evaluation; moderate incomplete paralysis warrants a 20 percent disability evaluation; moderately severe incomplete paralysis warrants a 40 percent disability evaluation; and severe incomplete paralysis with marked muscular atrophy warrants a 60 percent disability evaluation. An 80 percent disability rating is warranted for complete paralysis, where the foot dangles and drops, there is no active movement possible of the muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. The terms "mild," "moderate," and "severe" are not defined in the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, and the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under Diagnostic Code 5243, intervertebral disc syndrome may be rated under either the General Formula or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Under the Formula for Rating Intervertebral Disc Syndrome, incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months warrants a rating of 20 percent. Incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months warrants a rating of 30 percent. Incapacitating episodes having a total duration of at least 6 weeks during the past 12 months warrants a rating of 60 percent. Note (1): For purposes of evaluation under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. B. Evidence Private treatment records from September 2006 and April 2007 show the Veteran received epidural steroid injections to treat his back pain. These records also reflect diagnoses of lumbar radiculopathy. A VA examination was conducted in April 2008. The Veteran reported episodes of back pain which required self-prescribed bed rest. The most recent of these episodes was two years ago. His current treatment consisted mainly of epidural steroid injections. Since starting epidurals, he had not had any significant flare-ups of back pain and has not required any bed rest. He also wore an elastic lumbar support when doing yard work, and used a heating pad three to four times per week. He walked two miles three to four times per week without back problems. He stated that he could stand for about 15 minutes before experiencing back pain. On examination, the Veteran had a normal gait. There was slight tenderness at L4-S1 and over both sacroiliac joints. No spasms were present. Flexion was 60 degrees and extension was 20 degrees. Lateral flexion and rotation were both 30 degrees bilaterally. The examiner noted that range of motion was limited by mild discomfort. Repetitive motion caused no increase in pain, lost motion, weakness, fatigability, or incoordination. Straight leg raising was negative. Reflexes were absent in the lower extremities, but sensation was intact. Motor strength was 5/5. In a September 2008 statement, the Veteran reported having constant back pain. He was told by doctors that he could only receive three steroid injections. After that, his doctor recommended surgery, which he did not want. He experienced pain with manual labor, prolonged sitting and standing, and resting in bed for more than 6 hours. His job as a bus operator also exacerbated his pain. He also experienced spasms. Private records dated February 2009 show the Veteran felt somewhat weak in both lower extremities. On examination, there was no muscle wasting. He had good strength and normal tone in the extremities. Reflexes were moderately active and symmetrical. Sensation was unremarkable. The Veteran had a normal gait and station. Additional private records dated March 2009 show the Veteran reported pain ranging from 5/10 to 10/10 in severity. He also reported weakness in the left foot. On examination, straight leg raising was negative. Motor strength was 5/5, except in the tibialis anterior, which was 4/5. There was some numbness in the left foot. An April 2009 MRI revealed a moderate sized disc protrusion at L5-S1. There was an annular tear and slightly smaller protrusion at L4-L5. The examining physician noted that either protrusion could potentially cause back pain and radiculopathy. In May 2009, the Veteran received another steroid injection. VA records dated November 2009 show the Veteran reported intermittent pain which radiated down his right leg. He also reported numbness of the bilateral thighs. He denied any urinary or bowel incontinence. The Veteran underwent another VA examination in December 2009. He reported having constant low back pain, rated as 8/10 in severity. At times, it increased to 10/10. He also experienced radiating pain down the right thigh at least every other day, rated as 6/10 in severity. He also reported occasional numbness in the same area. He occasionally wore a brace if he did any yard work, and occasionally used a cane. He reported that his back did not interfere with his job as a bus driver. However, he experienced pain with 15 minutes of walking or 5 minutes of standing. He denied any urinary or fecal incontinence. On examination, the spine had normal curvature and no tenderness, deformity, or swelling. Forward flexion was 70 and extension was 17 degrees. Lateral flexion and rotation were both 20 degrees bilaterally. There was pain in the musculature during all range of motion tests. There was no additional loss of range of motion following repetitive testing. No muscle atrophy or spasm was present. Reflexes were 0 to 1+ in the lower extremities. No foot drop was present. Straight leg raising produced low back pain at 50 degrees on the right, and at 40 degrees on the left. Squatting was good. Heel and toe walking were normal. In April 2010, the veteran reported that his back pain was 8/10 in severity, and was increased by standing and walking. Pain affected sleep, physical and sexual activity, emotions, and concentration. Records from a podiatry consult in May 2010 reflect intact sensation and palpable pulses in both feet. Another VA examination was conducted in August 2011. The Veteran reported that his back "locked up" with prolonged driving or standing, and he has had to "roll" out of bed on occasion. He used a brace while doing yard work. He also reported using sick leave or vacation to allow him to rest his back. He denied any numbness, weakness, or incontinence. On examination, the Veteran had a normal gait. There was tenderness of the right lumbar paraspinous musculature without spasm. Forward flexion was 85 degrees and extension was 10 degrees. Rotation was 15 degrees bilaterally. Right lateral flexion was 30 degrees, and left lateral flexion was 25 degrees. There was pain throughout all ranges of motion. Repetitive testing resulted in increased pain without further loss of motion. Straight leg raising was negative to 90 degrees. Motor strength was 5/5 in the lower extremities. Reflexes were absent in the knees and ankles. Sensation was intact. The Veteran testified at a Board hearing in April 2012. He felt his range of motion had worsened since his last examination. He stated that, on a couple occasions, he had to crawl to the bathroom from his bed in order to reach his medication. He received steroid injections every six months to treat his condition. He stated that his back "locked up" with prolonged or strenuous use, such as yard work. He called in sick to work three to five times a year due to his back, and often had to stretch while working. He also experienced tingling in his back and hip once or twice per week. The Veteran was afforded an additional VA examination in January 2013 . He reported constant low back pain, rated as 8/10 in severity. Pain also radiated down the right thigh, and he had intermittent numbness in both thighs. He occasionally used a brace or cane. On examination forward flexion was 75 degrees and extension was 10 degrees. Lateral flexion was 15 degrees bilaterally, and rotation was 20 degrees bilaterally. Pain occurred at the end range of motion in all vectors. Measurements were unchanged following repetitive testing. There was no tenderness or spasm. Strength in the lower extremities was 4/5. Knee and ankle reflexes were 0. No muscle atrophy was present. Sensation was intact. Straight leg raising was negative bilaterally. The examiner stated that the Veteran did not have any signs or symptoms due to radiculopathy, and there were no other neurologic abnormalities present. The Veteran did not have incapacitating episodes. C. Analysis Based on the evidence, a rating in excess of 20 percent is not warranted for the Veteran's degenerative disc disease of the lumbar spine with stenosis and disc protrusion. As noted above, a higher 40 percent rating is warranted when forward flexion of the thoracolumbar spine is 30 degrees or less, or there is favorable ankylosis of the entire thoracolumbar spine. However, these criteria were not met at any point during the appeal period. At worst, forward flexion was 60 degrees, even when accounting for pain and other limiting factors. Notably, the Veteran experienced pain throughout the range of motion for forward flexion on multiple examinations. However, as noted above, pain alone does not constitute function loss. The Board also recognizes the Veteran's own reports of pain, the steroid injections and other treatment he has received, and his reports regarding the impact of his low back disability on his occupational duties and activities of daily living. In adjudicating a claim the Board must assess the competence and credibility of the Veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences; for example, he is competent to report that he experiences certain symptoms such as limited range of motion, pain, and numbness. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds the Veteran to be credible in his reports of the symptoms he experiences. However, forward flexion measurements during the appeal period were 60, 70, 85, and 75 degrees. Even when factoring the Veteran's account of his symptoms, the evidence does not demonstrate that he experiences an overall level of impairment consistent with either forward flexion of 30 degrees or favorable ankylosis of the thoracolumbar spine. As with the medical evidence of record, the Veteran's account of his symptomatology describes ratings consistent with the assigned 20 percent rating. The Board has also considered separate ratings for associated neurologic abnormalities. The record reflects a diagnosis of radiculopathy, and the Veteran reported symptoms of tingling, numbness, and radiating pain in his lower extremities. However, while reflexes in the lower extremities were diminished or absent throughout the appeal period, the January 2013 VA examiner noted that there were no signs or symptoms of radiculopathy, despite a similar finding during that examination. The only objective finding of radiculopathy symptoms was in the March 2009 private treatment records, which noted numbness in the left foot. Otherwise, the record shows normal findings with respect to gait, sensation, and muscle strength. May 2010 VA records also noted normal dermatological findings. In rating peripheral nerve injuries and their residuals, attention should be given to the relative impairment in motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Here, for the reasons listed above, the evidence does not demonstrate findings related to these criteria that correspond to a "mild" level of incomplete paralysis under Diagnostic Code 8520. Therefore, separate ratings for radiculopathy are not warranted. Finally, while the Board has considered a rating based on incapacitating episodes, the evidence does not reflect that the Veteran was prescribed bed rest by a physician at any point during the appeal period. Therefore, a rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes is not appropriate. D. Extraschedular Consideration In evaluating the Veteran's claims for higher ratings, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). As part of the evaluation for an extraschedular rating, the Board has considered the provisions of Mittleider v. West, 11 Vet. App. 181, 182 (1998), which holds that the benefit of the doubt applies to determinations of whether a symptom should be attributed to a service-connected condition. The Board has attributed all potentially service-connected symptoms to the Veteran's service-connected conditions in considering if the Veteran is entitled to an extraschedular rating. According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disabilities is inadequate. A comparison between the level of severity and symptomatology of the Veteran's low back condition with the established criteria found in the rating schedule for that condition shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology, as discussed above. The rating schedule specifically contemplates the Veteran's limited range of motion and neurological findings, and allows for higher or separate ratings which are not applicable in this case. There is no indication that the Veteran's condition results in any symptoms that fall so far outside the rating schedule as to render it inadequate. ORDER A rating in excess of 20 percent for degenerative disc disease of the lumbar spine with stenosis and disc protrusion is denied. REMAND Unfortunately, with respect to the Veteran's claim for service connection for an acquired psychiatric disorder, additional development is warranted. In its August 2012 remand, the Board instructed the RO/AMC that any post-remand supplemental statement of the case (SSOC) must include the recently amended regulations governing service connection for PTSD, which became effective July 13, 2010. Here, after completing the other requested development, the AMC issued an April 2013 SSOC which, in pertinent part, continued the denial for service connection for an acquired psychiatric disorder. However, the amended regulations for PTSD identified above were not included. As noted earlier, a remand by the Board confers on the veteran or other claimant, as a matter of law, the right to compliance with the remand orders. See Stegall v. West, 11 Vet. App. 268 (1998). Therefore, another remand is required for full compliance with the August 2012 remand instructions. Accordingly, the case is REMANDED for the following action: Readjudicate the Veteran's claim for service connection for an acquired psychiatric disorder (to include PTSD). If the claim remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case (SSOC), to include the recently-amended regulations governing service connection for PTSD, which became effective July 13, 2010. 38 C.F.R. § 3.304(f)(3). An appropriate period of time should be allowed for a response before returning the case to the Board. 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). ______________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs