Citation Nr: 18157093 Decision Date: 12/11/18 Archive Date: 12/11/18 DOCKET NO. 14-42 490 DATE: December 11, 2018 REMANDED Entitlement to service connection for right leg radiculopathy secondary to service-connected low back pains is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1967 to October 1970. This matter is on appeal from a March 2011 decision. In his October 2014 VA Form 9, the Veteran requested a videoconference hearing before a Veterans Law Judge. However, in August 2015, the Veteran withdrew his request for a hearing. Thus, the hearing request is deemed to be withdrawn. 38 C.F.R. § 20.704(d). Service Connection for Right Leg Radiculopathy An October 2013 VA treatment records notes that the Veteran was seen for an influenza vaccination in agreement with his primary care provider. The claims file contains a very limited amount of VA treatment records, from only June 2010, September 2010, and June 2013. There is also an indication that X-rays of the Veteran’s back were taken in April 2009, but there are no records showing the results of these X-rays. Although this notation was made in June 2010 VA treatment records, it is unclear whether the X-rays were completed by VA or by his private provider. As there is some indication in the file that there are missing treatment records, remand is warranted for the Veteran to identify all his treatment providers and to obtain X-ray results from April 2009. The Veteran was afforded a VA examination in January 2011, where he was diagnosed with right leg radiculopathy. However, the examiner found that the radiculopathy was less likely as not caused by or the result of his back disability. He explained that while the Veteran described pain radiating down the back of his thigh and the back of his leg down to the calf, it did not correspond to any dermatome. He noted that the straight leg raise test elicited some discomfort, but no paresthesias. He further indicated that the sitting root testing was negative, which “should rule out true radiculopathy.” In this case, the rationale provided is confusing. While the examiner diagnosed the Veteran with right leg radiculopathy, the examiner also indicated that the sitting root negative test result “should rule out true radiculopathy.” It is unclear what the examiner meant by “should rule out true radiculopathy,” whether the examiner felt that additional testing was needed, or anything else was needed. Additionally, the examiner did not provide an opinion as to whether the right leg radiculopathy was aggravated by the Veteran’s service-connected low back pains. An adequate medical opinion regarding secondary service connection must address causation and aggravation separately. See El-Amin v. Shinseki, 26 Vet. App. 136 (2013); see also 38 C.F.R. § 3.310(b). Therefore, remand for a new VA examination and opinion is necessary. The matter is REMANDED for the following actions: 1. Ask the Veteran to identify the provider(s) of all evaluations and treatment he has received for his radiculopathy, and to provide all releases necessary for VA to obtain the complete clinical records of such treatment or evaluation, to specifically include all records from the Veteran’s primary care provider, including any X-ray reports completed in April 2009. If any private records identified are not received pursuant to VA’s request, the Veteran should be so notified and advised that ultimately it is his responsibility to ensure that private records are received. 2. Obtain all available VA treatment records for the Veteran, including any X-ray reports from April 2009. 3. After completion of the development requested in items 1 and 2, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any right leg radiculopathy. The claims file, including a copy of this remand, must be made available to the examiner. The examiner must obtain a complete medical history from the Veteran, and any indicated tests and studies should be completed. The examiner is asked to provide opinions as to the following: a) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s right leg radiculopathy is proximately due to his service-connected low back pains. b) Whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s right leg radiculopathy was aggravated beyond its natural progression (i.e., any worsening of the condition beyond its natural progression) by service-connected low back pains. [If radiculopathy is found to have been aggravated by the service-connected low back pains, the examiner should quantify the approximate degree of aggravation.] A complete rationale for the medical opinion is required, which is based upon a review of the claims file and consideration of all evidence, including the Veteran’s statements. If an opinion cannot be expressed without resort to speculation, the examiner should so indicate and discuss why an opinion is not possible, to include 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. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Bonnie Yoon, Counsel