Citation Nr: 18157030 Decision Date: 12/11/18 Archive Date: 12/11/18 DOCKET NO. 16-42 784 DATE: December 11, 2018 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served in the United States Army from June 1969 to June 1971. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Board hearing in May 2017. A transcript is of record. Entitlement to service connection for a low back disability is remanded. A December 2012 VA examination report reflects a diagnosis of degenerative joint disease of the low back. Thus, the competent evidence shows a current low back disability. Regarding an in-service event/injury, the Veteran has consistently and repeatedly testified to the conditions of his service in Vietnam and the injury he suffered while serving. The Veteran reports that while in Vietnam he worked in an artillery unit, firing a 105 and 102 Howitzer. The Veteran has stated that he experienced a back injury due to lifting ammo shells while under heavy fire for three days. The Veteran asserts that he was taken to a hospital at a base in Ankhe for treatment of his back injury. Further, the Veteran has stated on numerous occasions that he has experienced back pain and trouble since the injury in Vietnam. The Veteran has provided such statements in support of claim in December 2006 and July 2012. In addition, the Veteran has also provided similar evidence in correspondence received in February 2013, statements provided to medical providers, and at the Veteran’s Board hearing in May 2017. The Veteran’s DD-214 confirms that the Veteran served in Vietnam, from November 1969 to October 1970, and the Veteran served in an artillery unit. The Board finds that DD-214 provides support to the Veteran’s statements regarding having duties of loading, unloading, and firing ammunitions. The record contains one indication of back pain in service, the report of medical history at separation notes back pain in May 1971, however, the record currently lacks any evidence of a back injury or the hospitalization at the base in Ankhe. In light of this, the Board finds that further evidentiary development is needed to evaluate the occurrence of a back injury during the Veteran’s service in Vietnam. Regarding an indication of a relationship to service, the record contains one VA examination, provided in December 2012, along with an addendum opinion obtained in July 2013. The Board finds the examiner’s December 2012 conclusion to be incomplete based on its reliance on a lack of documentation in the record. The examiner stated that without more documentation in the record, any opinion provided would be mere speculation However, a medical opinion based solely on the absence of documentation in the record is inadequate. Dalton v. Peake, 21 Vet. App. 23 (2007). The January 2013 addendum opinion, which relies on a lack of chronicity in finding no connection between the Veteran’s current low back disability and an in-service event or injury, lacks sufficient probative value to make a decision because of the minimal reasoning and explanation provided in the brief opinion. Therefore, the Board finds that a new VA examination with a nexus opinion necessary to evaluate the Veteran’s current back disability and its connection to the reported back injury in service. The matter is REMANDED for the following actions: 1. Contact the appropriate sources and request any available records concerning the Veteran’s military hospitalization for a low back injury while serving in Vietnam. 2. After association of the aforementioned records with the claims file, arrange for the Veteran’s record to be forwarded to an appropriate medical provider for VA examination regarding the etiology of his low back disability. Review of the claims file should be noted in the examiner’s report. The examiner is to provide a comprehensive rationale for any opinion offered. The examiner must consider lay reports from the Veteran along with pertinent medical evidence, including medical literature submitted by him. If the examiner cannot offer an opinion without resort to speculation, he or she should explain why and state what additional evidence, if any, would be required to offer an opinion. Based on a review of the record, the provider is to offer an opinion that responds to the following: Is it at least as likely as not (a 50 percent or better probability) that his current low back disability is related to his service? (Continued on the next page)   The Board points attention to the Veteran’s testimony regarding his MOS and a back injury suffered while serving in Vietnam. See Hearing Transcript (5/2017), DD 214, statements in support of claim (12/2006, 7/2012), and correspondence (2/2013). Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Watkins, Associate Counsel