Citation Nr: 18140305
Decision Date: 10/02/18	Archive Date: 10/02/18

DOCKET NO. 16-28 590
DATE:	October 2, 2018
REMANDED
Entitlement to a rating in excess of 40 percent for status post-lumbar microdiskectomy and anterior lumbar fusion is remanded.
REASONS FOR REMAND
The Veteran served on active duty from November 1989 to February 2008.
The Veteran seeks a rating in excess of 40 percent for his service-connected low back disability.  See February 2015 Notice of Disagreement.  The Board observes that the Veteran had a compensation and pension examination in January 2014.  The Veteran subsequently underwent lumbar surgery in August 2014. An additional VA examination is needed to assist in determining the post-surgery nature and severity of the service-connected low back disability.  In this regard, the Board recognizes that the Veteran underwent a VA spine examination in October 2016; however, this examination is inadequate for adjudication purposes for several reasons.  First, the examiner never reviewed the claims file in conjunction with the examination.  See Green v. Derwinski, 1 Vet. App. 121 (1991).  Moreover, a Supplemental Statement of the Case was not issued after the completion of the examination and no waiver of Agency of Original Jurisdiction is of record.  See 38 C.F.R. § 19.31.  Thus, a remand is required to conduct the appropriate examination and to issue a supplemental statement of the case.
The matter is REMANDED for the following action:
1.  Undertake appropriate development to obtain any outstanding records pertaining to treatment or evaluation of the Veteran’s service-connected status post-lumbar microdiskectomy and anterior lumbar fusion, to include both VA and private records.
2.  After all additional records are associated with the claims file, to the extent available, provide the Veteran with an appropriate examination to determine the severity of the service-connected status post-lumbar microdiskectomy and anterior lumbar fusion. status post-lumbar microdiskectomy and anterior lumbar fusion.  The entire claims file should be made available to and be reviewed by the examiner.  Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis.  An explanation for all opinions expressed must be provided. The examiner must utilize the appropriate Disability Benefits Questionnaire. 
The examiner must comment upon any lower back pain upon active motion, passive motion, weight-bearing, and nonweight-bearing.  If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so.
The examiner should identify the nature and severity of any neurological abnormalities, to include bowel or bladder impairment and lower extremity symptoms, e.g. radiculopathy, paresthesias, weakness, etc., resulting from the Veteran’s service-connected low back disability.  
The examiner is also requested to comment on the Veteran’s ability to function in an occupational environment in light of his back symptomatology and the effects of any medication prescribed therefor.  
A rationale in support of any opinions should be provided.
3. After the above development is completed, readjudicate the claim, with consideration of all evidence of record, to specifically include evidence associated with the record after the issuance of the April 2016 Statement of the Case (SOC).  If the claim is denied, issue a Supplemental SOC and allow the applicable time for response.  Then, return the case to the Board.
 
A. ISHIZAWAR
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	K.R.Fletcher, Counsel