Citation Nr: 18150757
Decision Date: 11/15/18	Archive Date: 11/15/18

DOCKET NO. 17-12 211
DATE:	November 15, 2018
REMANDED
Entitlement to service connection for a thoracolumbar spine disorder is remanded.
REASONS FOR REMAND
The Veteran served on active duty in the United States Army from August 1987 to March 1990.  This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO).
On appeal, the Veteran contends that his current back pain is the result of an injury in service when he “was hit in the lower back with [an] APC hatch.”  A review of his service treatment records does not demonstrate any complaints of, treatment for, or diagnosis of back pain or a back condition.  The Veteran was shown to have a normal back in June 1989 and October 1991 examination; in an October 1991 report of medical history, the Veteran denied any arthritis, rheumatism, or bursitis, or recurrent back pain.  
His VA treatment records also demonstrate complaints of chronic back pain and a notation from April 2015 that appears to be a diagnosis of degenerative disc disease based on an x-ray from January 2015; those records also indicate that he reported his back pain started during service after a truck accident.  The Veteran has not been afforded a VA examination regarding his thoracolumbar spine in this case.  
Although there is no evidence of treatment for a back injury during service, the Board finds that the low threshold for obtaining a VA examination in this case has been met.  A remand is therefore necessary in order for such to be accomplished.  See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006).
On remand, the Board also finds that any outstanding VA treatment records should also be obtained.  See 38 U.S.C. § 5103A(b), (c); 38 C.F.R. § 3.159(b); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016) (where the Veteran “sufficiently identifies” other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information); Bell v. Derwinski, 2 Vet. App. 611 (1992).
The matter is REMANDED for the following action:
1. Obtain any and all VA treatment records not already associated with the claims file from the San Juan VA Medical Center, or any other VA medical facility that may have treated the Veteran and associate those documents with the claims file.
2. Ensure that the Veteran is scheduled for a VA examination with an appropriate examiner in order to determine whether the Veteran’s thoracolumbar spine disorders are related to his military service or a service-connected disability.  The claims folder must be made available to and be reviewed by the examiner.  All tests deemed necessary should be conducted and the results reported in detail.  
Following examination of the Veteran and review of the claims file, the examiner should state any and all thoracolumbar spine disorders found, to include any degenerative disc disease (DDD) or any other arthritic condition thereof.  Then, for any thoracolumbar spine disorder found, the examiner should opine whether the such at least as likely as not (50 percent or greater probability) began in or is otherwise the result of military service, to include any injury to his back due to being hit by an APC hatch.  
In addressing the above, the examiner should consider the Veteran’s lay statements regarding onset of symptomatology and any continuity of symptomatology since onset and/or since discharge from service.  All findings should be reported in detail and all opinions must be accompanied by a clear rationale.
 
MARTIN B. PETERS
Acting Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Jacqulyn Lane, Associate Counsel