Citation Nr: 18149117
Decision Date: 11/08/18	Archive Date: 11/08/18

DOCKET NO. 16-40 914A
DATE:	November 8, 2018
REMANDED
Service connection for a lower back disability secondary to service-connected neck disability is remanded.
REASONS FOR REMAND
Service connection for a lower back disability secondary to service-connected neck disability is remanded.
The Veteran asserts that he has a lower back disability secondary to his service-connected neck disability.
At an April 2017 VA examination, the Veteran reported the onset of lower back pain with radiation into the left lower extremity in 2014.  He reported decreased range of motion and use of pain medication.  However, examination revealed no abnormalities of the lower back and the examiner indicated that the Veteran does not have a current diagnosis of a back disability.
VA medical records dated through November 2017 show a diagnosis of chronic lower back pain for which the Veteran was taking pain medication.  There is no radiographic evidence of a current back disability but in June 2017 a physician noted that all imaging of record pertained to the neck and recommended new imaging for the back.
While the Board appreciates the conclusion of the VA examiner that the Veteran does not have a current lower back disability, the record nevertheless indicates that the Veteran has symptoms of a lower back disability.  He complained of lower back pain with radiation into the left lower extremity at the VA examination.  VA medical records show a diagnosis of chronic lower back pain and recommendation for x-rays, which indicates the physician’s assessment that further diagnostic testing was needed to determine whether the Veteran has a lower back disability.  Thus, to ensure a complete record, all VA medical records since November 2017, to specifically include any x-rays of the lumbar spine, should be obtained.  The Veteran should then be afforded a new examination to determine whether he has a lower back disability secondary to his neck disability.
The matter is REMANDED for the following actions:
1. Obtain all VA medical records since November 2017, to specifically include any x-rays of the lumbar spine.
2. Schedule the Veteran for a VA examination to determine the etiology of any current lower back disability.  The examiner should review the claims file and note that review in the report.  The examiner should ensure that all indicated tests and studies are conducted, to include x-rays if not already contained in the medical records obtained on remand.  The examiner should provide an opinion on whether it is at least as likely as not (50 percent or greater probability) that any lower back disability had its onset during active service or within one year thereafter, or is otherwise causally related to such service.  The examiner should also provide an opinion on whether it is at least as likely as not (50 percent or greater probability) that any lower back disability was caused or aggravated by the service-connected neck disability.  The examiner should discuss the Veteran’s statements regarding the history and chronicity of symptomatology.  The examiner should provide a complete rationale for all conclusions.
3. Then, readjudicate the claim.  If any decision remains adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response.  Then, return the case to the Board.
 
KELLI A. KORDICH
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	J. W. Kim, Counsel