Citation Nr: 18144061 Decision Date: 10/23/18 Archive Date: 10/23/18 DOCKET NO. 16-26 707 DATE: October 23, 2018 REMANDED Entitlement to service connection for a lower back disorder is remanded. REASONS FOR REMAND The Veteran served honorably on active duty in the U.S. Army from June 1980 to May 1984, and in the U.S. Navy from March 1987 to March 1989. The Veteran had subsequent service in the Army Reserves with periods of active duty for training (ADUTRA) and inactive duty for training (INACDUTRA). This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Entitlement to service connection for a lower back disorder. Unfortunately, the VA etiological opinion of record in this case is inadequate and remand is required to obtain an adequate one. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Veteran underwent a VA back examination in May 2016. The Veteran was reported to have given a history of back pain in 1981 that had resolved when he left the Army in 1984. He then reported his back was “ok” when he entered Navy in 1985 but it started bothering him again in 1987, but was “ok” again at the time he was discharged in 1989. The examiner opined that diagnosed degenerative arthritis was not due to the Veteran’s period of service. The examiner explained there was no evidence in the service treatment records (STRs) of a back injury, only episodes of low back pain diagnosed as “muscle spasm” that resolved per findings recorded in an April 1988 physical examination. The examiner reported the Veteran was not diagnosed with degenerative disc disease until 2012, which was consistent with chronic bending and lifting as part of his work as a janitor. Thus, his current back condition was more than likely related to his 20 plus year career as a janitor. The examiner did not address all relevant STRs or back diagnoses, and did not address the Veteran’s reports of intermittent back pain since 1981. The Veteran’s STRs document complaints of back pain in May 1981, June 1981, July 1981, September 1981, March 1982, August 1982, December 1982, April 1983, July 1982, March 1984, and September 1987. Those STRs report assessments and diagnoses of paravertebral muscle spasm, lumbosacral strain, left sided sciatica, chronic lower back pain, and degenerative joint disease. While it is unclear whether degenerative joint disease was confirmed in service, the only in-service radiographs from December 1982 showed no abnormality and an April 1988 report of medical examination documented normal clinical findings for the spine, the in-service diagnosis was not addressed by the 2016 examiner. The examiner also did not address the in-service assessments of lumbosacral strain, left sided sciatica, and chronic lower back pain. Thus, remand is required for an addendum that accurately addresses the Veteran’s in-service back assessments. The 2016 examiner noted current diagnoses of degenerative arthritis and disc disease, however the record shows several other lower back diagnoses that need to be addressed. These diagnoses include left sided sciatica, mild retrolisthesis of L1 on L2, spondylolysis at L3-L4 and L5-S1 on the right side, piriformis syndrome, lumbosacral strain, myalgia, myositis, straightened lordosis, mild scoliosis, lumbago, and spinal enthesopathy. See December 2012 private radiology report; see January 2013 private MRI report; see February 2014 private case history report; see March 2014 private MRI report; see March 2014 Dr. NS record. Thus, remand is required to obtain clarification on the Veteran’s currently diagnosed lumbar spine disorders, and for an etiological opinion on each currently diagnosed disorder. Last, the examiner did not address the Veteran’s report history of chronic lower back pain, albeit intermittent with periods of no symptoms, since his initial 1981 lower back strain. See Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) (holding that the VA examiner’s opinion was inadequate where the examiner impermissibly ignored the appellant’s lay assertions that he had sustained a back injury during service). The Veteran’s reports of chronic, intermittent symptoms are consistent with the available treatment records and must be addressed on remand. The matter is REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the claimed lower back disorder from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. (a.) The examiner is requested to clarify all in-service and current lower back disorders. If a prior diagnosis was erroneous or no longer applicable, the examiner should so state. The following in-service diagnoses are noted in the Veteran’s STRs: paravertebral muscle spasm, lumbosacral strain, left sided sciatica, chronic lower back pain, and degenerative joint disease. The following post-service diagnoses are noted in private treatment records: lumbar spine degenerative arthritis, left sided sciatica, mild retrolisthesis of L1 on L2, spondylolysis at L3-L4 and L5-S1 on the right side, multilevel degenerative disc disease, piriformis syndrome, lumbosacral strain, sprain, myalgia, myositis, straightened lordosis, mild scoliosis, lumbago, and spinal enthesopathy. (b.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that each currently diagnosed lower back disorder had onset in, or is otherwise related to, active service. (c.) The examiner must specifically address the following: 1) the Veteran’s testimony that he first experienced lower back pain in 1980, which has chronically occurred on an intermittent basis since then and worsened over time; 2) the STRs documenting treatment for lower back symptoms in May 1981, June 1981, July 1981, September 1981, March 1982, August 1982, December 1982, April 1983, July 1982, March 1984, and September 1987; 3) a December 2012 private radiology report; 4) a January 2013 private MRI report; 5) a February 2014 private case history report; 6) a March 2014 private MRI report; and 7) a March 2014 Dr. NS record. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Smith, Associate Counsel