Citation Nr: 1742201 Decision Date: 09/25/17 Archive Date: 10/04/17 DOCKET NO. 10-22 156 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for a lower back condition, to include degenerative joint disease. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD B. Gabay INTRODUCTION The Veteran served on active duty in the United States Army from November 1966 to November 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which denied the claim. This matter was remanded by the Board in November 2013 and September 2016. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND In November 2013, the Board remanded this matter for a new VA examination. Specifically, in its remand directives, the Board asked the examiner to render an opinion as to whether it is at least as likely as not that the Veteran's current lower back disability was etiologically related to service. The examiner was also asked to address whether the symptoms the Veteran exhibited in service in 1968, after he was thrown from a Jeep, were early symptoms or manifestations of the rheumatoid arthritis with which he was diagnosed in 2003. The January 2014 VA examination, conducted in response to the Board's remand, noted the Veteran's diagnoses of facet degenerative joint disease of the lumbar spine and degenerative disc disease L3 to L5. The examiner stated that the Veteran's current conditions were not a manifestation of his rheumatoid arthritis diagnosis. The examiner's rationale was that the in-service event was clearly documented as discomfort from the Jeep accident, and that rheumatoid arthritis, on the other hand, is an inflammatory condition and would have nothing to do with the Jeep accident. The examiner further indicated that there were no objective findings to link the muscle pain in 1968 to the medical notations of chronic back pain that began in 1999. Rather, the examiner determined that it was more likely that the Veteran's degenerative disc disease and facet arthropathy were related to his age, genetics, rheumatoid disease, and post-service lifestyle. While the January 2014 examination generally addressed the Board's remand directives, the examiner did not adequately address whether the Veteran's in-service injuries were early symptoms or manifestations of the Veteran's rheumatoid arthritis that was diagnosed in 2003. Nor did the examiner address the Veteran's lay statements regarding the onset of the Veteran's low back disability or continuity of symptomatology, per the Board's directives. Lastly, the examiner failed to provide a thorough rationale for her opinion that the Veteran's degenerative joint disease at L3-L5 was not related to the injury he sustained to his low back at L2-L5, while he was in service. Because of these inadequacies, the Board remanded this matter in September 2016 for a new spine examination. The Board directed the new examination to address whether the Veteran's degenerative joint disease is etiologically related to service, to include the severe pain at L2-L5 he experienced following the Jeep accident in October 1968. Additionally, the Board directed the examiner to the January 2014 X-ray report showing marked degenerative disk disease at L3 to L5 with osteoarthritic changes involving articular facets, and asked the examiner to specifically comment if the condition could be related to the Veteran's October 1968 in-service injury to his lower back. The Board also directed the examiner to consider the Veteran's May 2004 report of a diagnosis of a bulging disc 25 years earlier and comment on whether the condition could be related to the Veteran's in-service injury. Lastly the Board directed the examiner to determine whether the injuries the Veteran sustained in the 1968 automobile accident or the severity of pain he experienced were early symptoms or manifestation of the Veteran's rheumatoid arthritis diagnosed in 2003. In January 2017, the Veteran underwent a second VA examination, per the Board's directives. The Veteran was once again diagnosed with degenerative arthritis of the spine. Imaging studies revealed marked degenerative disk disease at L3 to L5 with osteoarthritic changes involving articular facets. The examiner noted the Veteran's 2003 diagnosis of seronegative rheumatoid arthritis. The examiner concluded that the Veteran's current condition was less likely than not incurred in or caused by the in-service injury, providing the rationale that "no military documents are in the c file which support the accident. On separation examination on 10/25/1968 there was no mention of back pain." The examiner further stated his belief that the Veteran's spinal condition was due to post-military vocation, including 30 years general labor, obesity, and age. Finally, the examiner stated that the Veteran's existing diagnosis of seronegative rheumatoid arthritis "is most of his pain." At no point during this examination did the examiner address the following: (1) whether the Veteran's current degenerative joint disease could be related to the severe L2 to L5 pain he experienced following the Jeep accident in October 1968; (2) whether the marked degenerative disk disease at L3 to L5 with osteoarthritic changes involving articular facets could be related to the Veteran's October 1968 in-service injury to his lower back; (3) whether the May 2004 report of a diagnosis of a bulging disc 25 years earlier could be related to the Veteran's in-service injury; (4) whether the injuries the Veteran sustained in the 1968 automobile accident or the severity of pain he experienced thereafter were early symptoms or manifestation of the Veteran's rheumatoid arthritis diagnosed in 2003. The Board finds that the January 2017 VA examiner's opinion discussed above is inadequate, and therefore a remand is necessary in order to provide an addendum opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide a medical examination or opinion, it must ensure that the examination or opinion is adequate). The Board notes that medical opinions are regarded as more probative when they include clear conclusions and supporting data with a reasoned analysis connecting the data and the conclusions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this case, the VA opinion of record falls well short of the Board's directives, and is therefore insufficient to support a final judgment. Accordingly, the case is REMANDED for the following action: 1. Return the claims file to the examiner who completed the January 2017 examination, if available, for an addendum opinion, regarding whether the Veteran's lower back condition is etiologically related to his active duty service. The examiner should clarify his opinion regarding the cause of the Veteran's degenerative disc disease. Specifically, the examiner should address: a. whether the Veteran's current degenerative joint disease could be related to the severe L2 to L5 pain he experienced following the October 1968 in-service injury; b. whether the marked degenerative disk disease at L3 to L5 with osteoarthritic changes involving articular facets could be related to the Veteran's October 1968 in-service injury; c. whether the May 2004 report of a diagnosis of a bulging disc 25 years earlier could be related to the Veteran's October 1968 in-service injury; d. whether the injuries the Veteran sustained in the 1968 automobile accident or the severity of pain he experienced thereafter could be early symptoms or manifestation of the Veteran's rheumatoid arthritis diagnosed in 2003. 2. After the above has been completed, the RO must review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 3. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, in whole or in part, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. 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 2014). _________________________________________________ Cynthia M. Bruce 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) (2016).