Citation Nr: 1339733 Decision Date: 12/03/13 Archive Date: 12/18/13 DOCKET NO. 12-06 801 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for a back disorder. REPRESENTATION Appellant represented by: Oklahoma Department of Veterans Affairs ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran served on active duty from January to June 1955. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma, in which the RO denied service connection for a left hand injury and a back injury/degeneration. In his March 2012 VA Form 9, the Veteran indicated that he was only appealing the claim for service connection for a back injury. Therefore, only this issue is currently in appellate status. See 38 C.F.R. § 20.200 (2013) (an appeal to the Board consists of a timely filed notice of disagreement (NOD) in writing and, after receipt of a statement of the case (SOC), a timely filed substantive appeal). The Board has reviewed the contents of the Veteran's Virtual VA file and found that it contains additional medical evidence that has been considered by the RO in the February 2012 SOC. Therefore, the Board's consideration of this evidence will not result in prejudice to the Veteran. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). This appeal is REMANDED to the Department of Veterans Affairs Regional Office. VA will notify the appellant if further action is required. REMAND Remand is required to afford the Veteran a VA examination regarding his claimed back disorder and to obtain outstanding treatment records. 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. Request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his back disorder. 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 Dr. C.D.W., dated prior to and since April 2011; and (2) treatment records from the Oklahoma City VA Medical Center (VAMC) (to include the Lawton outpatient clinic (OPC)), dated prior to July 2008 and since January 2012. If any identified records are not obtainable (or none exist), the Veteran and his representative should be notified and the record clearly documented. 2. After all available records have been associated with the claims file and/or Virtual VA e-folder, afford the Veteran a VA examination to determine the etiology of his back disorder. 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 current back disorder. 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. As indicated above, the examiner should review the record in conjunction with rendering the requested opinion; however, his or her attention is drawn to the following: * The Veteran asserts that his current back disorder is related to an in-service injury when he fell down stairs. In April 2011, he reported that his back did not hurt until a couple of days after this fall. The following month, he reported falling down stairs and fracturing his hand during basic training. He described back pain ever since the fall and commented that it had worsened over the years. * The Veteran has submitted lay statements in support of his report of back pain since service. In May 2011, the Veteran's wife wrote that she met the Veteran in July 1955 and he had had back pain in the 56 years she had known him. She reported that around August 1955 he went to a doctor for adjustments to alleviate his back pain. In a May 2011 letter, B.C. wrote that Dr. H.R.C. saw the Veteran from 1972 to 2010, during which time he treated him for back pain. A June 2011 letter from L.D.T. reports that he had known the Veteran since 1966 and he had had pain on the different jobs he had worked with him on. * On separation examination in June 1955, clinical evaluation of the spine was normal. * In July 2001, the Veteran complained of intractable pain syndrome in the right hip and leg, developing about a month earlier. Dr. D.R.S. reviewed a lumbar MRI which revealed a herniated and caudally extruded disk on the right below the L4/5 level. The Veteran underwent right L4-5 laminectomy with microlumbar discectomy. * An April 2011 treatment record from Dr. C.W.D. reflects an impression of lumbar degenerative disc disease (DDD) and lumbar intervertebral disk disease with myelopathy. * In a June 2011 letter, Dr. W.L.D. reported treating the Veteran since 1978, at which time he presented with lumbar symptoms. In rendering the requested opinion, the examiner must consider the Veteran's reports of back pain since an in-service fall. The examiner is advised that the Veteran is competent to describe symptoms of back pain and is competent to report the in-service injury. All examination findings, along with a complete explanation for all opinions expressed, should be set forth in the examination report. 3. Conduct any other appropriate development deemed necessary. Thereafter, readjudicate the claim, considering all evidence of record. If the benefit sought remains denied the Veteran and his representative should be provided an SSOC. An appropriate period of time should be allowed for a response. The appellant has the right to submit additional evidence and argument on the matter that 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. 2013). _________________________________________________ KELLI A. KORDICH Acting 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).