Citation Nr: 18151677 Decision Date: 11/20/18 Archive Date: 11/19/18 DOCKET NO. 16-48 151 DATE: November 20, 2018 REMANDED Entitlement to service connection for low back disability is remanded. REASONS FOR REMAND The Veteran had active service from March 1971 to June 1971. 1. Entitlement to service connection for low back disability is remanded. Medical evidence of record includes a letter from a private provider in February 1971 explaining that the Appellant had sought treatment for his back prior to service induction and was diagnosed with an acute lumbosacral strain with a moderate bilateral paravertebral muscle spasm and decreased range of motion due to pain. Dr. F.R. noted painful straight leg raises. The Appellant was scheduled for, but did not return for a follow-up examination, and was assumed to have made a complete uneventful recovery from his acute lumbosacral strain. An additional letter from April 1971 stated the Appellant had last been examined in February 1971, at which time he had a mild pulling sensation on the right during leg raises but was otherwise negative for further symptoms. Following the medical review and entrance examination, the Veteran began active duty in March 1971. No disability of the lumbar spine was noted. He sought medical treatment for his low back in April 1971. In May 1971, the Veteran was found medically qualified for duty with temporary assignment limitations due to chronic back pain, probable herniated nucleus pulposus at L5-S1, old, with recurrent right S1 nerve root irritation. The Veteran was referred to the Medical Board in May 1971. Although the Veteran was found to be medically fit for retention, the Medical Board found that he was erroneously inducted into service and the Veteran was discharged based on that finding. The examiner noted a concern over aggravating a preexisting back disorder. The Appellant contends that he currently experiences chronic low back pain and lumbar radiculopathy due to his active military service. On review there are questions as to whether the Veteran had a low back disability prior to entering active service, whether any preexisting low back disorder was aggravated by active service, and whether a relationship exists between any current low back disorder and his active service. A medical examination is needed to address these questions. The matter is REMANDED for the following action: 1. Obtain any outstanding VA treatment records. Contact the Appellant to determine whether there are any additional relevant private treatment records and obtain any necessary authorizations for such records. 2. After completion of the foregoing, schedule the Appellant for an examination to determine the nature and etiology of any low back disorder. Based on a review of the records, examination, and consideration of the lay evidence, the examiner should address the following: (a.) Identify/diagnose any chronic low back and lower nerve disorder that presently exists or that has existed during the appeal period. (b.) State whether the is clear and unmistakable evidence (undebatable) that the Appellant had a disability of the low back and/or lumbar spine prior to entering active service. If such a determination is made, identify and discuss the evidence used to support that finding. (c.) For any disability of the low back and/or lumbar spine found to have preexisted active service, state whether there is clear and unmistakable evidence that the disability was not aggravated beyond its natural progression by the Appellant’s active service. (d.) For each identified disorder, state whether it is at least as likely as not (50% probability or better) that the Veteran’s current disability of the low back and/or lumbar spine, including sciatic neuropathy, had its onset in service or is otherwise related to his active service. The examiner must opine on whether the Veteran’s current diagnosis was caused by or related to the above discussed in-service low back condition or is in any other way related to the Veteran’s active service. A complete rationale for any opinion expressed must be provided. An examiner’s report that he or she cannot provide an opinion without resort to speculation is inadequate unless the examiner provides a rationale for that statement. As such, if the examiner is unable to offer an opinion, it is essential that the examiner provide a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide the opinion is based on the limits of medical knowledge. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M.E. Lee, Associate Counsel