Citation Nr: 18140922 Decision Date: 10/09/18 Archive Date: 10/09/18 DOCKET NO. 15-00 625A DATE: October 9, 2018 REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to service connection for the residuals of a head injury is remanded. Entitlement to service connection for migraines, to include as secondary to a head injury, is remanded. REASONS FOR REMAND The Veteran had active service from December 1972 to February 1976. These matters come before the Board of Veterans Appeals (Board) on appeal from an October 2014 rating decision by the VA regional office (RO). The Veteran testified before the undersigned at a hearing in January 2018. The Board finds that further development is required prior to the adjudication of the Veteran’s claims of entitlement to service connection for a back, head, and migraine disability. First, regarding the Veteran’s back and head injuries, the record reflects that there may be outstanding VA treatment records that have not been associated with the claims file. Specifically, at his January 2018 hearing the Veteran testified that he received treatment at the Evansville and Lancaster VAMCs for his disabilities. The claims file does not appear to contain these VA treatment records. Accordingly, the AOJ should obtain any outstanding VA treatment records on remand. See 38 U.S.C. § 5103A(c); 38 C.F.R. § 3.159(c)(2); Bell v. Derwinski, 2 Vet. App. 611, 612 (1992) (noting that VA medical records are in constructive possession of the agency and must be obtained if pertinent). With specific regard to the back disability, the Veteran has been diagnosed with degenerative disc disease of the back in an April 2018 private DBQ. Furthermore, with regard to an in-service injury, the Board notes that the Veteran’s February 1976 report of medical history reflects his reports of recurrent low back pain. On the accompanying report of medical examination, his spine was found to be clinically normal. Given that the claims file does not include a VA examination and opinion as to whether the Veteran’s low back disability is due to his service. See 38 C.F.R. § 3.159; McClendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). With regard to the Veteran’s head and migraine disabilities, the Board finds at the Veteran’s March 2018 DBQ the examiner, Dr. L.A., noted the Veteran’s history of an October 2017 VA neurology report at which time neurologist Dr. K.B. found that his dizziness and blacking out was due to his diagnoses of subclavian stenosis and subclavian steal. With respect to an in-service injury, the Veteran has reported at his January 2018 Board hearing that he experienced a fall during service in November 1975 when he hit his head on a cement ashtray. He noted he was treated at a hospital in Camp Lejeune for his head injury. See January 2018 Hearing transcript p. 27. The Veteran’s military personnel records reflect that he served at Camp Lejeune in 1975, but his records do not include hospitalization records from Camp Lejeune. The Board observes that in-service hospital records can be stored separately from other service treatment records at the National Personnel Records Center (NPRC) and a specific request for in-service hospital records must be made to the NPRC separate from any request for other service treatment records. The Board further acknowledges that the Veteran’s available service treatment records have been associated with the claims file. Therefore, on remand the AOJ should contact the NPRC and attempt to obtain the Veteran’s in-service hospital records. The matters are REMANDED for the following action: 1. Attempt to obtain any outstanding STRs. Specifically contact the appropriate repository and request that they provide any in-service hospital records, to include x-rays, for the Veteran dated in 1975 specifically at Camp Lejeune. In particular, the Board is trying to obtain records from Camp Lejeune hospital dated in November 1975 after hitting his head on a cement ashtray and incurring stitches. A copy of any request(s) sent to the NPRC, and any reply, to include any hospital records obtained in response to this request, should be associated with the claims file. 2. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. In particular, the Board is trying to obtain records from the following VA facilities: Lancaster, CA from 1976; Evansville, IN from 1978 to 1980; and Nashville, TN from 1987 to the present. A search for any archived records should be requested. 3. Thereafter, schedule the Veteran for a VA examination to determine the etiology of his back disability. The clinician is asked to provide an opinion as to whether it is as likely as not that any diagnosed back disability is caused by or related to the Veteran’s service, specifically to include his reports of being thrown down on the field in 1974 while wearing his radio equipment. 4. If and only if the requested hospital records document the Veteran’s reported in-service head injury in 1975, the clinician is asked to provide any current diagnoses of the head, to include headache. Thereafter, the clinician is asked to provide an opinion as to whether it is as likely as not that any diagnosed residuals of a head injury, to include headache, is caused by or related to any in-service injury, specifically relating to falling and hitting a cement ashtray while in service in November 1975. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Kamal, Associate Counsel