Citation Nr: 1338002 Decision Date: 11/20/13 Archive Date: 12/06/13 DOCKET NO. 11-10 749 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a left lower extremity disability, claimed as left leg pain and stiffness, to include as secondary to service-connected degenerative disc disease of the lumbar spine. 2. Entitlement to service connection for a right lower extremity disability, claimed as left leg pain and stiffness, to include as secondary to service-connected degenerative disc disease of the lumbar spine. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD Christopher Murray, Counsel INTRODUCTION The Veteran had active military service from May 1980 to February 1982. This case comes before the Board of Veterans' Appeals (Board) on appeal of a June 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The Veteran and his spouse testified before the Board at an April 2013 hearing conducted via videoconference. A transcript of the hearing is of record. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran asserts service connection for disabilities of the bilateral lower extremities is warranted as secondary to his service-connected degenerative disc disease of the lumbar spine. He has testified that he suffers from radiating pain, weakness and numbness of both lower extremities. During the development of his claim, the Veteran was provided a VA examination in September 2010. The examiner found there were no signs of radiculopathy, but also noted that the Veteran had never been provided EMG or nerve conduction testing. Such testing was not provided at the September 2010 VA examination, rendering this examination inadequate for the purposes of determining service connection. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence...is essential for a proper appellate decision"). To date, there remains no diagnosis of record of a separate disability of either lower extremity attributable to the Veteran's service-connected lumbar spine disability. While the Veteran submitted a June 2013 statement from J.G., M.D. linking his bilateral leg pain, weakness and numbness to his lumbar spine disability, this statement also does not indicate that such symptomatology is actually a separate diagnosed disability such as radiculopathy. Given the deficiency of the record, the Veteran must be provided a new VA examination to determine whether he suffers a separate diagnosed disability of the lower extremities and, if so, whether such disability is secondary to his service-connected degenerative disc disease of the lumbar spine. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request he identify all medical facilities which have treated him for his claimed disabilities of the bilateral lower extremities. For any non-Federal facility identified, the Veteran should be requested to complete and return the appropriate medical release authorization forms. Following receipt of these forms, the AOJ should undertake the necessary attempts to obtain these records. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of any disability of the lower extremities resulting in pain, weakness and/or numbness. The entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner in conjunction with the examination. If the examiner does not have access to Virtual VA, any relevant treatment records contained in Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. All necessary testing must be completed including, but not limited to, EMG and/or nerve conduction testing. Following a review of the record, and physical examination of the Veteran, the examiner is requested to address the following: a. Identify any clinically diagnosed disability of either the left and/or right lower extremity manifested by leg pain, weakness and numbness. b. For each diagnosed disability, provide an opinion as to whether it is at least as likely as not (probability of at least 50 percent) that such disability is proximately due to (caused by) the Veteran's service-connected degenerative disc disease of the lumbar spine. c. If (b) is answered no, provide an opinion as to whether it is at least as likely as not (probability of at least 50 percent) that such disability is aggravated by (chronically worsened beyond normal progression) the Veteran's service-connected degenerative disc disease of the lumbar spine. d. If the examiner finds that the Veteran does not have a disability of the lower extremities that is either proximately due to, or aggravated by the Veteran's service-connected degenerative disc disease of the lumbar spine, is it at least as likely as not that such disability is otherwise related to the Veteran's military service. A complete rationale must be provided for all opinions expressed. 3. After completing the above, and any other development deemed necessary, readjudicate the Veteran's claim based on the entirety of the evidence. If the benefits sought on appeal are not granted to the appellant's satisfaction, he and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. 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). (Continued on the next page) This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ S. L. Kennedy 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).