Citation Nr: 18142347 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 17-45 250 DATE: October 15, 2018 REMANDED Entitlement to service connection for residuals of a low back injury is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1958 to August 1959. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a December 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. In June 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The Board also notes that he submitted additional evidence in January 2018 and June 2018 for consideration in his appeal. 38 U.S.C. § 7105(e)(1). Entitlement to service connection for residuals of a low back injury. The Veteran contends that, while stationed at Lake Charles Air Force Base (which has been redesignated as Chennault Air Force Base) in 1959, he injured his low back and was hospitalized. In this regard, while he indicated that details of his injury are hazy, he recalled carrying a heavy pack over long distances, and had to lift heavy objects while on kitchen patrol. The Veteran further alleges that he continues to experience pain and loss of motion in his back, and his friend of 35 years, D.D., reported that he had witnessed the Veteran’s back complaints over the years. Therefore, he claims that service connection for residuals of a low back injury is warranted. The Veteran’s service treatment records are negative for complaints, treatment, or a diagnosis referable to a low back injury or disorder. At the time of his August 1959 separation examination, his spine was normal upon clinical evaluation. Further, while the Agency of Original Jurisdiction (AOJ) attempted to obtain all clinical records related to the Veteran’s alleged inpatient treatment at Lake Charles/Chennault Air Force Base, no records were found. However, his reports of carrying a heavy pack over long distances and lifting heavy objects while on kitchen patrol are consistent with his service as an enlisted airman. After service, a July 1962 VA examination conducted for unrelated complaints reflected that there were no abnormal findings upon examination of the Veteran’s musculoskeletal system. However, VA treatment records dated from September 1964 to October 1964 reflect diagnoses of spondylolysis, L5, and low back pain of unknown etiology. In this regard, it was noted that the Veteran developed low back pain in November 1963 while climbing out of an elevator that was stuck between floors. Such persisted for three weeks and then resolved, until February 1964 when he again developed low back pain while lifting a patient. Additionally, current VA treatment records reflect complaints of low back pain and a December 2017 CT scan revealed a new T12 central compression fracture with approximately 50 percent height loss and 3mm retropulsion. Therefore, as the Veteran has a current low back disorder, has reported in-service duties consisting of heavy lifting, and he and D.D. have indicated a continuity of back symptomatology, the Board finds that a remand is necessary in order to afford the Veteran a VA examination so as to determine the current nature and etiology of his low back disorder. Further, as the Veteran testified to receiving treatment for his low back disorder from a private physician and through VA, he should be given an opportunity to identify any records relevant to the claim on appeal that have not been obtained. Thereafter, all identified records, to include updated VA treatment records dated from June 2017 to the present, should be obtained. The matter is REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records, to include updated VA treatment records dated from June 2017 to the present, should be obtained. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Afford the Veteran an appropriate VA examination so as to determine the nature and etiology of his low back disorder. The record, to include a copy of this Remand, should be forwarded for review by the examiner. All indicated tests should be conducted. Thereafter, the examiner should address the following inquiries: (A) Identify all current low back disorders. (B) For each currently diagnosed low back disorder, please offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such is related to the Veteran’s military service, to include carrying a heavy pack over long distances, and lifting heavy objects while on kitchen patrol. (C) If arthritis of the low back diagnosed, please indicate whether such manifested within one year of the Veteran’s separation from service in August 1959, i.e., by August 1960, and, if so, please describe the manifestations. In offering such opinions, the examiner should consider the Veteran’s and D.D.’s statements regarding the onset and continuity of back symptomatology. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Robert Almosd, Associate Counsel