Citation Nr: 18158890 Decision Date: 12/19/18 Archive Date: 12/18/18 DOCKET NO. 16-36 216 DATE: December 19, 2018 REMANDED Entitlement to service connection for lumbar spine disorder is remanded. Entitlement to service connection for left lower extremity neuropathy and/or radiculopathy as secondary to a lumbar spine disorder is remanded. Entitlement to service connection for right lower extremity neuropathy and/or radiculopathy as secondary to a lumbar spine disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1965 to October 1986. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a March 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. 1. Entitlement to service connection for lumbar spine disorder. 2. Entitlement to service connection for left lower extremity neuropathy and/or radiculopathy as secondary to a lumbar spine disorder. 3. Entitlement to service connection for right lower extremity neuropathy and/or radiculopathy as secondary to a lumbar spine disorder. The Veteran contends that he has a lumbar spine disorder, and associated bilateral lower extremity neuropathy and/or radiculopathy, as a result of his military service. In this regard, he alleges that, due to the in-service duties he performed as an aviation machinist mate for 20 years, which required lifting and carrying heavy items and sitting for long periods of time on aircraft, he developed back pain. Further, he claims specific injuries to his back during service that included an eight-foot nose dive off an aircraft work stand in 1966, a fall on his rear after slipping on oil on the hangar deck, and hard landings during his more than 3000 flights. The Veteran also reports that he has experienced back pain during and since his service, which has subsequently resulted in bilateral lower extremity neuropathy or radiculopathy. Therefore, he claims that service connection for a lumbar spine disorder, and associated bilateral lower extremity neuropathy and/or radiculopathy, is warranted. The Veteran’s service treatment records reflect that, in March 1966, he fell off an aircraft work stand. While back complaints were not noted, he fractured a tooth and cut his upper lip. He was given ice pack and admitted to the sick list for two days. In July 1977, the Veteran was treated for a low back muscle strain after doing heavy lifting for two weeks. During an August 1977 follow up, the Veteran reported that his low back pain improved but was still present. He was advised to take caution and care on use of his back and to stay on firm mattress. He was ordered to stay away from heavy lifting or tenuous exercises until his back problem was fully resolved. On his June 1986 Report of Medical History, the Veteran reported recurrent back pain and cramps in his legs and trick or locked knee, and the examiner noted “back pain – “sciatica” [left] hip.” Additionally, in an April 2012 statement, the Veteran’s neighbor and friend from 1975-1976 indicates that the Veteran had experienced back pain since the time they met. The Veteran’s post-service treatment records document extensive treatment for a lumbar spine disorder, and reflects his complaints of neurological symptoms affecting the bilateral lower extremities, which have been diagnosed as neuropathy and radiculopathy. In light of the foregoing, the Veteran was afforded a VA examination in May 2013 in order to ascertain the nature and etiology of his claimed disorders. At such time, degenerative disc disease of the lumbosacral spine, status post fusion, with an onset date in 2003, and arthritis were diagnosed. Notably, the X-ray did not show a vertebral fracture. The examiner also noted the presence of bilateral radicular pain, without objective evidence of radiculopathy, as secondary to the lumbar spine disorder, and sensory polyneuropathy of the bilateral lower extremities unrelated to the lumbar spine disorder. Following an interview with the Veteran, a review of the record, and a physical examination, the examiner, a neurologist, opined that the lumbar spine disorder and associated radicular pain were less likely as not caused by or a result of his military service, to include the back strain treated in July 1977 and the notation of back pain with sciatica reported in June 1986. In support of such opinion, he observed that there was no objective evidence of a chronic back condition in service and there was nothing to suggest the presence of degenerative disc disease or radiculopathy. The examiner indicated that, while sciatica was noted in June 1986, such was not shown in his service treatment records and it was mentioned as “left hip;” however, sciatica would not cause left hip pain by itself. Rather, it would involve pain going down the left leg. He further observed that there was no evidence of a chronic back problem or sciatica for several years following separation from service, and a June 2003 record suggested that his back disorder with radicular pain became worse in 1997 when he started to build a log cabin. Consequently, the examiner found that he could not establish a chronic low back or peripheral nerve condition that began in service and, thus, a nexus cannot be made. Further, the examiner opined that the Veteran’s intermittent leg pain appeared to be radicular and is likely caused by his low back disorder, but his numbness of the feet and findings of a sensory polyneuropathy is very unlikely to be related to, or aggravated by, his low back disorder. However, he did not provide a rationale for such opinion. Subsequent to the May 2013 VA examination, the Veteran indicated that the examiner failed to consider that he had trauma to his L-4 vertebrae as evidenced by a fracture and rotation on an MRI. He further reported that his surgeon had informed him that he had idiopathic neuropathy that was probably caused by long term nerve damage caused by the spinal trauma. In this regard, the Board notes that there is no imaging report in the file that demonstrates a vertebral fracture; however, a June 2012 record reflects bilateral paresthesias and peripheral neuropathy potentially related to his lumbar spine disorder. The Veteran further clarified that he did not do heavy lifting during the building of his log cabin in the 1990s. Additionally, the record reflects that the Veteran underwent a second spinal fusion subsequent to the May 2013 VA examination in May 2015. Moreover, while the May 2013 VA examiner addressed the documented in-service treatment and reports regarding the Veteran’s back complaints, he did not address whether his in-service duties or injuries resulted in his current back disorder. Consequently, the Board finds that a remand is necessary in order to attempt to obtain any outstanding records referable to the claims on appeal, to include any imaging reports that reflect trauma, including a vertebral fracture, to the spine, and an addendum opinion addressing the aforementioned matters. The matters are REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal, to include any imaging reports reflecting trauma (fracture and rotation) to the L-4 vertebrae. After obtaining any necessary authorization from the Veteran, all outstanding identified records should be obtained. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. After obtaining any outstanding records, return the record to the VA examiner who conducted the May 2013 back examination. The record and a copy of this Remand must be made available to the examiner. If the May 2013 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a full review of the record, the examiner should address the following inquiries: (A) For each diagnosed lumbar spine disorder, please offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such is related to the Veteran’s military service, to include the in-service duties he performed as an aviation machinist mate for 20 years, which required lifting and carrying heavy items and sitting for long periods of time on aircraft, and/or his reported injuries, to include an eight-foot nose dive off an aircraft work stand in 1966, a fall on his rear after slipping on oil on the hangar deck, and hard landings during his more than 3000 flights. (B) Please offer an opinion as to whether the Veteran’s arthritis of the lumbar spine manifested within one year of his separation from service in October 1986, i.e., by October 1987, and, if so, please describe the manifestations. (C) For each diagnosed bilateral lower extremity neuropathy and/or radiculopathy, please offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such is caused or aggravated by the Veteran’s lumbar spine disorder. For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. In offering such opinions, the examiner should consider the Veteran’s and his neighbor/friend’s statements regarding the onset and continuity of back and lower extremity symptomatology. A rationale for any opinion offered must be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Robert Almosd, Associate Counsel