Citation Nr: 18152019 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 17-27 025 DATE: November 20, 2018 REMANDED Service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty for training from July 2009 to December 2009 and on active duty from January 2010 to January 2011, to include service in Southwest Asia. The record reflects the Department of Veterans Affairs (VA) attempted to obtain the Veteran’s complete service treatment records. Some of the Veteran’s service records were obtained from his National Guard unit, but complete service records were not provided. In an April 2012 VA Memorandum the Regional Office (RO) detailed efforts made to locate the Veteran’s service treatment records. The memorandum indicates that all efforts to obtain the needed military information has been exhausted and further efforts are futile based on the facts. The RO determined that the complete service treatment records are not available for review. Later that month the Veteran was notified that VA was unable to obtain the Veteran’s service treatment records and that future efforts to locate them would be futile. The Veteran was provided an opportunity to submit additional information to locate his treatment records or to submit any treatments records in his possession. Service treatment records reflect the Veteran was treated for chronic lumbar strain and lumbosacral musculoskeletal tightness causing nerve root irritation. In November 2010 the Veteran reported he felt a sharp pain in his back while searching vehicles in July 2010 and reported his initial injury dated back to boot camp while doing heavy lifting. In June 2015 the Veteran underwent VA examination. The Veteran reported that he was treated for low back pain in service in basic training from carrying a log and that wearing gear during deployment and looking under cars as a security guard bothered his low back. The examiner reported the Veteran denied injuring his back from trauma. The Veteran reported receiving treatment after active duty service and that he went to physical therapy with little help. He reported taking over the counter medication and reported he cannot perform heavy lifting or carrying, bending, prolonged walking or standing, or sitting due to low back pain. The examiner diagnosed lumbar strain with mild degenerative joint disease per x-ray. He reported a more precise diagnosis cannot be rendered as there is no objective data to support a more definitive diagnosis. He reported that it was less likely than not that the Veteran’s current low back disability was caused by or a result of active duty service. He explained that there is no objective evidence to support this as chronic ongoing complaints or treatment for low back per service medical records review. He reported that review of the medical literature suggests degenerative joint disease usually takes several years to develop after injury not the same year as suggested in this case. The examiner reported there is no objective evidence of aggravation and the Veteran has gained significant weight since his deployment and has worked as a security guard for many years, both well-known contributing factors to low back disabilities. He explained that to what degree these factors, plus natural aging has on the Veteran’s current low back disability would be mere speculation. After the June 2015 VA examination the Veteran provided an April 2016 operative report and additional copies of his service treatment records, some of which were not previously of record. The Veteran’s private operative report reflects that he was diagnosed with L4-5 and L5-S1 degenerative disk disease with foraminal stenosis and retrolisthesis of L4 and L5. His private treatment provider reported a history of chronic back pain after an injury in the military along with some radiculopathy. Service records not available to the June 2015 examiner reflect in an October 2010 sworn statement the Veteran reported he felt a tweak in his lower back while searching a car and that two days later he again felt a sharp pain in his lower back while searching vehicles. He reported he notified his commanding officer and was out for the rest of his shift and signed up for sick call. A January 2013 National Guard record indicates that the Veteran was evaluated by the Florida Army National Guard Medical Review Board and found unable to perform his military duties due to his back condition. As VA has received additional service records pertaining to the Veteran’s low back disability the Board finds remand is warranted to obtain a supplemental medical opinion as to the etiology of the Veteran’s current low back disabilities. The matter is REMANDED for the following action: The claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the current diagnoses for lumbosacral strain with degenerative disc disease, and degenerative joint disease is related to an in-service injury, event, or disease. In offering the opinion, the examiner is asked to consider the Veteran’s lay statements that he injured his back during basic training and during deployment searching vehicles, service treatment records that reflect complaints for chronic lumbar strain and lumbosacral musculoskeletal tightness causing nerve root irritation, a November 2010 Statement of Medical Examination and Duty Status, January 2013 National Guard record that reflects limitations of duty due to a back condition, and April 2016 private operative report. The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as the Board is precluded from making any medical findings. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Gonzalez, Associate Counsel