Citation Nr: 18158454 Decision Date: 12/17/18 Archive Date: 12/14/18 DOCKET NO. 17-02 458 DATE: December 17, 2018 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1990 to September 1990, with additional Reserves service that included periods of INACDUTRA and ACDUTRA. Low Back Disability The Veteran contends that his back condition was caused by or aggravated by his active duty service, to include his additional ACDUTRA and INACDUTRA Reserves service. The Board notes that the Veteran was never provided a VA examination for his claimed condition. VA’s duty to assist includes providing a medical examination and obtaining an opinion when it is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d) (2012); 38 C.F.R. § 3.159 (2017). Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of a diagnosed disability or symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). The threshold for finding a link between a current disability and service so as to require medical examination is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. Here, the Veteran has been diagnosed with lumbago and congenital spondylosis. Additionally, his service treatment records (STRs) show he was seen in June 1990 for low back pain and spondylosis of the spine. Further, although the Veteran’s back pain was noted as having occurred from an incident prior to service, and/or as a congenital back disability, an opinion on whether it is clear and unmistakable the Veteran entered service with a preexisting spondylosis back disability is needed. Given this, the Board finds that a remand is required in order to obtain a medical examination with an opinion addressing the nature and etiology of the claimed condition. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matter is REMANDED for the following action: 1. Obtain and associate with the Veteran’s electronic claims file any outstanding VA and private treatment records relevant to the Veteran’s back disability. The RO is also instructed to make all necessary attempts to confirm any ACDUTRA and INACDUTRA periods of Reserve service and any service records from such periods. 2. After all outstanding records have been associated with the claims file, schedule the Veteran for an examination with an appropriate examiner to determine the etiology of any low back disability. The record and a copy of this Remand must be made available to the examiner. Following a review of the entire record, to include the Veteran’s competent lay statements, as well as the Veteran’s report regarding the onset and progression of his current symptomatology, the examiner should opine as to the following: (a) Is it clear and unmistakable that the Veteran entered active military service with a pre-existing spondylosis back condition? (b) If YES, is it clear and unmistakable that the Veteran’s pre-existing spondylosis condition WAS NOT aggravated beyond the natural progress of the disorder by his active military service, to include the onset of his back pain? In other words, please determine whether it is clear and unmistakable that there was no increase in disability during service or that it is clear and unmistakable that any increase in disability was due to the natural progress of the pre-existing condition. (c) If the Veteran DID NOT clearly and unmistakably enter active military service with a pre-existing spondylosis condition, is it at least as likely as not (50 percent probability or more) that the Veteran’s back condition is related to his period of active service, to include his June 1990 complaint of back pain and notation of spondylosis. In offering any opinion, the examiner must consider the full record, to include the lay statements regarding in-service incurrence, and the opinion should reflect such consideration. A clearly stated rationale for any opinion offered should be provided and must not be based solely on the lack of any in-service records. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain whether the inability is due to the limits of the examiner’s medical knowledge, medical knowledge in general or there is evidence that, if obtained, would permit the opinion to be provided. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Negron, Associate Counsel