Citation Nr: 18159996 Decision Date: 12/21/18 Archive Date: 12/20/18 DOCKET NO. 17-05 401 DATE: December 21, 2018 REMANDED Entitlement to service connection for degenerative arthritis, lumbar spine, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1978 to August 1982 with additional periods of active duty for training in the Army National Guard and Army Reserve. The Veteran has asserted that she injured her lower back in 1978 while stationed at Fort Rucker, Alabama. She described being on a detail clearing out an old hospital, where she was breaking up hearing booths and loading slabs of the former walls into a truck. Some fell onto her back at the mid-back region. She stated that she sought care and was placed on light duty and given medications. She reported that her condition improved but she has had low back pain since then. She also described reinjuring her low back when loading and unloading trucks going out to the field as part of a medevac unit, although the specific date of this occurrence was not indicated. The Veteran’s service treatment records (STRs) from her active duty service in the Army are unavailable. Substantial development has been previously undertaken by the Regional Office (RO) to attempt to associate those records with the claims file without success. Additionally, the Veteran has reported that she had a copy of the STRs from that period of service, but they were destroyed in a fire. There are no indications regarding lumbar spine injury or pain in the available STRs. The Veteran did not report any complaints or symptoms regarding her lumbar spine at National Guard examinations in November 1982, March 1994, or September 1996, however she did indicate a current condition of arthritis in the November 1982 report. The Veteran underwent a VA examination in October 2016 of her entire thoracolumbar spine. She was diagnosed with chronic rhomboid strain of the thoracic spine/myofascial pain (for which she is separately service-connected) and degenerative arthritis of the lumbar spine. The examiner determined that it was as least as likely as not that the thoracic spine condition was incurred in service, but did not provide an opinion regarding the lumbar spine disorder. The Board finds that an opinion is needed to determine whether the degenerative arthritis of the lumbar spine may be related to the injury she described as occurring in 1978. The matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate VA clinician to address the Veteran’s degenerative arthritis of the lumbar spine. The claims file should be made available for review and noted as such in the examination report. Special attention is invited to the November 1982, March 1994, and September 1996 examination reports, and the Veteran’s contentions regarding her injuries and complaints. The need for a new examination is left to the discretion of the clinician. After a review of the claims file, the clinician should address the following: (a.) Please identify the likely etiology for each lumbar spine disability diagnosed. Specifically, is it at least as likely as not (a 50 percent or better probability) that any is related to the Veteran’s service, and in particular, the injury she described as occurring in 1978. (b.) The clinician is asked to explain the rationale for all opinions, citing to supporting factual data and medical literature, as appropriate. If he or she determines that the questions cannot be resolved without resorting to speculation, then an explanation as to why this is so should be provided. 2. Thereafter, review the record and readjudicate the Veteran’s claim. If the claim remains denied, the Veteran and her representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. MICHAEL E. KILCOYNE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Rachel E. Jensen, Associate Counsel