Citation Nr: 1803602 Decision Date: 01/19/18 Archive Date: 01/29/18 DOCKET NO. 14-13 762 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for a low back condition. ATTORNEY FOR THE BOARD R. I. Sims, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1978 to June 1986, February 2003 to September 2003, January 2004 to February 2004, and January 2006 to February 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a April 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia that denied service connection for a low back condition. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND In his March 2013 notice of disagreement (NOD), the Veteran asserts that he has experienced back pain for approximately 10 years as result of military service as a fighter/attack aircraft pilot. The Veteran reports he was told by a flight surgeon that such back pain was normal. The Veteran also asserts he was injured during his deployment to Iraq between 2006 and 2007. Specifically, the Veteran states that he was in a vehicle that jumped a curb, which aggravated his back. He reports treatment at the Baghdad Orthopedic Clinic on three occasions and a diagnosis of a pinched nerve. Additionally, the Veteran reports documenting problems with his back on a questionnaire before he left Iraq and upon returning home to Camp Pendleton. January 2009 private treatment records indicate the Veteran was diagnosed with lumbago. At that time, he exhibited significant subjective complaints of pain and a positive shopping cart sign, but objective testing showed no significant abnormalities and his physical exam was unremarkable. Additional treatment records indicate clinical impressions of lumbar spine dysfunction and the Veteran reported seeing a spinal surgeon, Dr. Lowery. February 2009 private treatment records indicate that the Veteran was diagnosed with degenerative disc disease of the lumbar spine. May 2010 private treatment records indicate the Veteran was pain free without functional limitations. April 2011 treatment records indicate the Veteran was weightlifting and "had an excruciating episode of severe low back pain." At that time, the Veteran walked with an antalgic gait and experienced reduced range of motion with forward flexion to about 30 degrees, and pain and spasm thereafter. An outside CT scan was reviewed and showed mild degenerative changes. The Veteran was assessed with lumbago and lumbar strain. The April 2011 CT of the lumbar spine indicates mild disc bulges at L3-L4 and moderate degenerative changes of the facet joints with ligamentum favum hypertrophy resulting in mild canal stenosis and mild left and moderate right neuroforaminal narrowing. Mild disc bulging at L4-L5 and mild degenerative changes of the facet joints with ligamentum favum hypertrophy resulting in mild canal stenosis and moderate bilateral neuroforaminal narrowing, left greater than right. Unfortunately, VA has been unable to locate some of the Veteran's service treatment records. Service records from 2000 and 2002 indicate that the Veteran reported positives for back or neck pain. Accordingly, the case is REMANDED for the following action: 1. Obtain any private treatment records and/or VA treatment records for the Veteran's back from 2011 to the present. 2. Obtain a VA examination and opinion regarding the Veteran's low back condition. The examiner should obtain a detailed medical history of the Veteran's low back condition, to include, but not limited to, the onset of his low back pain and any relevant circumstances around such onset. The examiner should also identify any current thoracolumbar spine disabilities. After review of the Veteran's claims file, including his credible statement noted above from the March 2013 notice of disagreement, and the detailed medical history obtained, the examiner should address the following question: Is at least as likely as not (50 percent or greater) that the Veteran's degenerative disc disease, lumbar spine dysfunction, facet joint hypomobility, or lumbar vertebrae sensitivity to p-a oscillations, was incurred during a period of active military service (March 1978 to June 1986, February 2003 to September 2003, January 2004 to February 2004, and January 2006 to February 2007). Why or why not? In so doing, the examiner should consider the Veteran's reports of being in a vehicle that hopped a curb in Iraq and his MOS as a pilot. The examiner should also consider the Veteran's back injury following weightlifting in 2011, as well as the fact that he had been seen for back complaints prior to that injury. 3. Then readjudicate the appeal. If the claim remains denied, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate time for response. The Veteran has the right to submit additional evidence and argument on the matter 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. §§ 5109B, 7112 (2012). ______________________________________________ MATTHEW W. BLACKWELDER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs