Citation Nr: 18147622 Decision Date: 11/05/18 Archive Date: 11/05/18 DOCKET NO. 15-32 536 DATE: November 5, 2018 REMANDED Entitlement to an initial rating in excess of 20 percent for a lumbar spine strain is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from March 1980 to July 1980 and in the Army National Guard from July 1980 to January 2000. In an August 2018 Additional Evidence Response Form, the Veteran agreed to waive initial Agency of Original Jurisdiction (AOJ) review of additional evidence that was submitted in his claim. With respect to the Veteran’s increased rating claim, remand is necessary to obtain clarification regarding whether the Veteran has suffered from an objective neurologic abnormality, including radiculopathy, that is associated with his lumbar spine condition. Upon initial VA examination in October 2010, radiculopathy was not noted and the neurological examination conducted as part of the Veteran’s spine examination was normal. However, the Veteran was seen by his VA treatment provider in May 2011 for an evaluation of back pain that radiated down his right leg and up his back to his neck. He was assessed as having lower back pain with radiculopathy and prescribed Gabapentin. VA treatment notes from June 2011 also show that the Veteran complained of increased trouble with numbness in the bilateral upper extremity for the past month. It was noted that the Veteran had a history of lumbar spine degenerative joint disease (DJD)/disc disease (DDD) and that he had been started on Gabapentin approximately two weeks earlier for radiculopathy. After an evaluation, the Veteran was assessed as having “probable cervical DJD/DDD with mild radiculopathy”; the Veteran is not service-connected for a cervical spine disability. VA treatment notes from January 2014 provide an assessment of “lumbar DDD with no clear radicular symptoms.” Upon examination in October 2015, the examiner also indicated the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. However, in the medical history section of the examination report, it was noted he had reported back pain and pain into his legs. The Veteran’s medical records were not reviewed by that examiner. In a disability benefits questionnaire completed in August 2018, the examiner noted the Veteran’s reports of pain in his lumbar spine that radiated into his neck. Upon evaluation, the examiner indicated the Veteran had no radicular symptoms in the right lower extremity and moderate constant pain, intermittent pain, paresthesias and/or dysesthesias, and numbness in his left lower extremity. She also specified the left sciatic nerve was involved and that his radiculopathy was caused by degenerative changes in the lumbar spine. It is unclear how she came to this determination considering the Veteran reported pain radiating to his neck at the time of that examination. An addendum opinion is necessary to determine whether the Veteran has had radiculopathy in either of his upper or lower extremities associated with his lumbar spine condition (versus his cervical spine) at any time during the period on appeal. With respect to TDIU, consideration of entitlement to a TDIU is dependent upon the impact of the Veteran’s service-connected lumbar spine condition on his ability to obtain or retain substantially gainful employment. Accordingly, the matter of a TDIU is inextricably intertwined with the Veteran’s increased rating claim for service-connected lumbar spine strain. Harris v. Derwinski, 1 Vet. App. 180 (1991). Remand of the inextricably intertwined TDIU claim is therefore required. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran has or has had at any time during the period on appeal, an objective neurologic abnormality, to specifically include radiculopathy of the upper or lower bilateral extremities, associated with his service-connected lumbar spine condition. The Veteran’s electronic claims file and a copy of this remand should be reviewed by the clinician. The references to radiculopathy made in the claims file, including those noted above, should be addressed by the clinician. If any associated objective neurologic abnormality is identified, the severity of the abnormality should be discussed. Specifically, the clinician should state the degree of impairment present, which should be expressed as complete or incomplete paralysis of any nerve. The specific nerve(s) involved must be identified. If incomplete paralysis is found, the clinician should state whether the incomplete paralysis is best characterized as mild, moderate, or severe (with the provision that wholly sensory involvement should be characterized as mild, or, at most, moderate). If the clinician determines that a physical examination is necessary to provide any requested opinion, such should be scheduled. A fully articulated rationale shall be provided for each opinion with references to lay and medical evidence as needed. If the clinician cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R.Vemulapalli, Associate Counsel