Citation Nr: 1632265 Decision Date: 08/15/16 Archive Date: 08/24/16 DOCKET NO. 12-11 246 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a lumbar spine disability. 2. Entitlement to service connection for a cervical spine disability. REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL Appellant and Spouse ATTORNEY FOR THE BOARD A. Stone, Associate Counsel INTRODUCTION The Veteran had active service from August 1964 to September 1967. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In connection with this appeal, the Veteran and the Veteran's spouse testified at a hearing before the undersigned Veterans Law Judge at the RO in January 2016. A transcript of that hearing is of record. REMAND Unfortunately, the Board finds that more development is required before the claims on appeal can be decided. There are outstanding records that need to be obtained and associated with the claims file. Additionally, the Veteran has not been provided a VA examination that addresses the claims for service connection for a lumbar back disability and cervical back disability. The Board finds that a remand is warranted to schedule the Veteran for a VA examination and medical opinion. An October 2009 private medical record diagnosed postlaminectomy syndrome, and degenerative disk disease of the lumbar spine with stenosis. March and April 2002 private medical records diagnosed herniated cervical disc with radiculopathy and degenerative disc disease. The January 2016 hearing testimony of the Veteran and the Veteran's spouse noted that the Veteran served as a nuclear weapons storekeeper at Ammunition Depot Earle, in Colts Neck, New Jersey. His duties included handling, as a member of a team, warheads that were 100 pounds and 15 feet long, with 5 foot long casings, and which each weighed 50 pounds. In the summer or fall of 1966 the Veteran was involved in an accident while loading the warhead casings when five of the casings fell on top of him, pinning him down, and striking him on the back of the neck at the base of the skull and striking his back, causing him to become disoriented. He was treated at Patterson Army Hospital, at Fort Monmouth, New Jersey, where he spent two nights, had x-rays taken, and received at least 40 stitches on the back of his neck. During the hearing the Veteran showed a scar on the back of his neck. Two weeks following the accident, the Veteran played football and was injured in the neck and back, and was given pain pills and muscle relaxers. Prior to service he had no neck or back condition. In 1967, he injured his back again in training and took pain pills and muscle relaxers, but did not want to see a doctor. Since service he had received treatment for the neck and back and had experienced subsequent injuries. His first back surgery was in1969. His second neck injury was sustained playing golf, and his second back surgery was in 1987, after which he could not run, lift, or tie his shoes. He received 100 percent disability from the Social Security Administration. He currently is treated by a general doctor, who prescribes anti-inflammatories, and a muscle relaxer for his neck, and by a neurologist for tremors as a result of the hit to the back of his head. He traveled to St. Louis to obtain his entire service medical and hospitalization records, but was unsuccessful. The Veteran's lay statement contained in the November 2009 Application for Compensation and/or Pension also notes that following the second injury to his neck and back in Fall 1966, the Naval Base Infirmary prescribed a neck brace and limited duty. Unfortunately, the Veteran's military personnel records are not of record. Those records, which may include documentation of the inservice events described by the Veteran at the hearing, and any physical profiles placing the Veteran on limited duty, need to be obtained and associated with the record. The hospitalization records of Patterson Army Hospital, in Fort Monmouth, New Jersey, also need to be obtained and associated with the claims file. A portion of the Veteran's Fall 1966 service medical records appear to be missing and also need to be obtained and associated with the claims file. Prior to arranging for the Veteran to undergo further examination, VA should obtain and associate with the record all outstanding VA records. Dunn v. West, 11 Vet. App. 462 (1998); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Obtain all outstanding VA medical records and private medical records of treatment for lumbar and cervical spine disabilities and associate them with the claims file. 2. Obtain the Veteran's outstanding service medical records, in particular from June 1966 through December 1966, including any hospitalization records from Patterson Army Hospital, Fort Monmouth, New Jersey, and associate them with the claims file. If those records are not available, all efforts to obtain them and any negative responses received must be documented in the claims file. 3. Obtain the Veteran's outstanding service personnel records, and associate them with the claims file. If those records are not available, all efforts to obtain them and any negative responses received must be documented in the claims file. 4. Then, schedule the Veteran for a VA examination with a medical doctor for the purpose of ascertaining the nature and etiology of any lumbar spine disability. The examiner must review the claims, and the report should indicate that review, including review of service medical records showing that the Veteran had back problems in service in 1966; the October 2009 private medical record showing that the Veteran has a diagnosed postlaminectomy syndrome, and degenerative disk disease of the lumbar spine with stenosis; an October 2008 private medical record from the Social Security Administration (SSA) showing that the Veteran had a greater than 40 years of low back pain; and that SSA established October 1, 2009, as the beginning date for back and neck disability. All appropriate tests should be conducted. The examiner should consider the lay statements regarding onset, inservice injuries, and continuity of symptomatology since service. Dalton v. Nicholson, 21 Vet. App. 23 (2007). The examiner should provide a complete rationale for all opinions and conclusions and reconcile them with all pertinent evidence of record. Specifically, the examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that any current lumbar spine disability was incurred in active service or is related to service. 5. Then, schedule the Veteran for a VA examination with a medical doctor for the purpose of ascertaining the nature and etiology of any cervical spine disability. The examiner must review the claims file and the report should indicate that review, including review of service medical records showing that the Veteran had neck problems in service in 1966; the March and April 2002 private medical records showing that the Veteran had a diagnosed herniated cervical disc with radiculopathy and degenerative disc disease; an October 2008 Social Security Administration (SSA) record showing that SSA established October 1, 2009, as the beginning date for back and neck disability. All appropriate tests should be conducted. The examiner should consider the lay statements regarding onset, inservice injuries, and continuity of symptomatology since service. Dalton v. Nicholson, 21 Vet. App. 23 (2007). The examiner should provide a complete rationale for all opinions and conclusions and reconcile them with all pertinent evidence of record. Specifically, the examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that any current cervical spine disability was incurred in active service or is related to service. 6. Then, readjudicate the claim on appeal. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then return 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 or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2015).