Citation Nr: 18155885 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 12-03 133 DATE: December 6, 2018 REMANDED Service connection for a back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1986 to February 1993. The Veteran testified before a Veterans Law Judge (VLJ) at an October 2014 videoconference hearing. A transcript of this hearing is of record. In October 2017, the Veteran was notified that the VLJ who held his October 2014 hearing was no longer employed by the Board. The Veteran indicated that he did not want another Board hearing and requested that the Board consider his case on the evidence of record. In January 2018 the Board remanded this appeal for further development. Service connection for a back disability is remanded. A remand is necessary to ensure that there is a complete and accurate record upon which to decide the Veteran’s claim so that every possible consideration is afforded. The Veteran is service connected for a left ankle disability. The Veteran has stated that his left ankle instability caused him to fall in-service in 1998 and 1992 as well as after service in 2004. See September 2010 statement. The most recent VA examiner opined that his back disability was not caused or aggravated by his left ankle but did not provide any rationale. See May 2018 VA opinion. In addition, in November 2005 Dr. C., an orthopedic surgeon, opined that “the [May 2004] work related injury has caused stress reaction and micro fracture through his pedicle which was compromised from an underlying benign osseus lesion.” See November 2005 treatment records. The May 2018 VA opinion cited to this 2005 opinion in concluding the Veteran’s back disability was not related to back injuries in service. However, the VA examiner did not state whether the underlying lesion could be related to injuries in service. Therefore, a new examination must be obtained to consider service connection on a direct and secondary basis. The Board notes that the Veteran submitted a private medical opinion in November 2014. Dr. A.W. opined the Veteran’s back disability was related to his service, however, he did not provide any rationale for this opinion. Therefore, the Board finds it inadequate. The matter is REMANDED for the following action: 1. Schedule the Veteran with an appropriate specialist for an examination to determine the cause of his back disability. The Board notes that this case was previously remanded and recognizes that the complex and intertwined nature of the medical questions involved require significant work on the part of the medical examiner. The Board regrets the need to remand the matter again to the RO, however, the Board is unable to adjudicate the Veteran’s case until it has the requested information. Therefore, the Board must ask the VA examiner and the RO to ensure compliance with these directives (that is, full and thoroughly explained answers to each of the questions) to avoid additional delays in adjudication. After review of the claims file, the examiner should address the following: a. Is it at least as likely as not (50 percent probability or greater) that the Veteran’s back disability had its onset in or is otherwise related to service? In providing this opinion, the examiner is requested to address the May 1988 service treatment records noting a back injury resulting in an area of erythema and abrasion at T10-L2, April 1992 service treatment records noting a back injury from volleyball and imaging showed sacralization of L5 on the right, and May 2004 private treatment records documenting a back injury when the Veteran fell exiting a work vehicle. The examiner must also address the cause of the underlying osseus lesion discussed by Dr. C in November 2005 treatment records. b. Is it at least as likely as not (50 percent probability or greater) that the Veteran’s back disability was proximately caused by his service-connected left ankle disability. The examiner must consider the Veteran’s September 2010 statement that the instability of his left ankle caused him to fall and injure his back in 1988, 1992, and 2004. 2. After completing the requested actions, and any additional development deemed warranted, readjudicate the claims in light of all pertinent evidence and legal authority. If the benefits sought remain denied, furnish to the Veteran a Supplemental Statement of the Case and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. D’Allaird, Associate Counsel