Citation Nr: 18144326 Decision Date: 10/25/18 Archive Date: 10/24/18 DOCKET NO. 16-38 815 DATE: October 25, 2018 REMANDED Entitlement to a rating in excess of 10 percent for T11 compression fracture and degenerative disc disease of the thoracolumbar spine (back disability) is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1980 to January 1984, from January 1984 to January 1989 and from November 2001 to September 2003. Entitlement to a rating in excess of 10 percent for T11 compression fracture and degenerative disc disease of the thoracolumbar spine (back disability) is remanded. The Veteran was afforded his most recent VA spine examination in June 2012, over six years ago. The Board also notes that the Veteran has alleged that he was not examined thoroughly during the June 2012 examination. See January 2014 notice of disagreement and August 2016 VA Form 9. Given the Veteran’s reports and the fact that it has been over six years since the Veteran was last examined, the Board finds that a remand for a more contemporaneous VA examination is warranted. Green v. Derwinski, 1 Vet. App. 121 (1991) (VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the rating of the disability will be a fully informed one); Caffrey v. Brown, 6 Vet. App. 377 (1994) (an examination too remote for rating purposes cannot be considered "contemporaneous"). Current medical records show that the Veteran has reported increasing back pain since his June 2012 examination, and the Veteran has reported that his spine fracture has worsened and that he experiences back spasms. See VA outpatient treatment records from Mattoon Community Based Outpatient Clinic, the VA Medical Center in Indianapolis, the Illiana Health Care System, and private treatment records from the Carle Physician Group Pain Clinic. See also August 2016 claim for increased rating. VA's General Counsel has indicated that when a claimant asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Given the evidence of increased symptomatology, a new VA examination is warranted to determine the current severity of the Veteran's back disability. The matter is REMANDED for the following action: 1. Updated treatment records should be obtained and added to the claims folder/e-folder. 2. Following completion of the above, afford the Veteran a VA spine examination to determine the current severity of his service-connected back disability. The claims folder should be made available to the examiner for review in connection with the examination and the examiner should acknowledge such review in the examination report. Any testing deemed necessary should be performed, including X-rays and appropriate range of motion studies. All clinical findings should be recorded in detail, to include range of motion testing for active motion, passive motion, weight-bearing, and nonweight-bearing to the extent possible. If the examiner is unable to conduct the required testing, he or she should clearly explain why that is so. In reporting the results of range of motion testing, the examiner should specifically identify the points, if any, at which pain begins. The examiner should determine whether the low back disability is manifested by weakened movement, excess fatigability, incoordination, pain or flare-ups. These determinations should be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, pain or flare ups. The examiner should identify any nerves affected by the back disability and severity of that disability. The examiner should also indicate whether there is any form of ankylosis. The examiner should identify any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment. The examiner should specifically identify the frequency and duration of any periods of bed rest with treatment prescribed by a physician. In addition, the examiner should indicate whether, and to what extent, the Veteran likely experiences functional loss due to pain and/or any other symptoms noted above during flare-ups and/or with repeated use; to the extent possible, the examiner should express any additional functional loss in terms of additional degrees of limited motion. 3. After completing the above, and any other development deemed necessary, readjudicate the Veteran's claim, based on the entirety of the evidence. If the benefit sought on appeal is not granted to the Veteran's satisfaction, he and his representative should be provided with a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. The case should then be returned to the Board, if otherwise in order. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD F. Yankey, Counsel