Citation Nr: 18153790 Decision Date: 11/28/18 Archive Date: 11/28/18 DOCKET NO. 16-53 093 DATE: November 28, 2018 ORDER Entitlement to service connection for lumbar spine degenerative disc disease is remanded. REMAND The Veteran served on active duty in the United States Navy from March 1977 to March 1981. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2014 rating decision by the Department of Veterans Affairs (VA), Regional Office (RO) in Columbia, South Carolina. The Veteran presented sworn testimony at a Travel Board Hearing before the undersigned Veterans Law Judge (VLJ) in May 2017. A transcript of the hearing is of record. REASONS FOR REMAND The Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). To be considered adequate, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In addition, a medical examiner is not free to simply ignore a veteran’s lay statements recounting symptoms or events. Dalton v. Nicholson, 21 Vet. App. 23 (2007). The Veteran was afforded a VA spine examination in June 2014. Lumbar spine degenerative disc disease with degenerative arthritis was assessed. The examiner stated that the Veteran’s current diagnosis was less likely than not incurred in or caused by the claimed in service injury. The VA examiner explained that the Veteran had normal lumbar x-rays in 1978, days after his injury. The examiner further stated that there was no evidence of a back condition upon separation in 1981. The Veteran’s service medical records show that the Veteran suffered a fall and injured his lower back while on board his Navy vessel in April 1978. The x-rays of the Veteran’s back were normal. Following the examination, a strain was assessed. Several days of rest, medication, and stretching was prescribed to treat the condition. At his May 2017 hearing, the Veteran testified that he experienced back problems after falling onto the sharp edge of a wooden bunk. He further testified that he began seeking treatment for his back from a Chiropractor in the 80’s and continued to see his Chiropractor for a number of years. He also testified that he had undergone three back surgeries, all of which the Veteran felt were a result of the injury sustained to his back in service. The Board notes that the Veteran’s statements were made subsequent to the June 2014 VA examination, and therefore, could not be considered by the examiner. As such, the Veteran’s lay statements must be addressed by a VA examiner on remand. On remand, relevant ongoing medical records should be obtained. 38 U.S.C. § 5103A (c) (2012); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, this case is REMANDED for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran’s claim, to include all chiropractor records noted in the Veteran’s testimony during his May 2017 Board hearing. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159 (e). 2. Then, afford the Veteran a VA examination by an examiner with sufficient expertise, who has not previously performed an examination or proffered an opinion in this case, to determine the nature and etiology of his low back disability. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner must state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s low back disability was incurred in, was caused by, or is otherwise etiologically related to his military service. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 3. Then readjudicate the issue on appeal. If the benefit sought on appeal is not granted to the Veteran’s satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Dion Roberts, Law Clerk