Citation Nr: 18160799
Decision Date: 12/27/18	Archive Date: 12/27/18

DOCKET NO. 16-14 360
DATE:	December 27, 2018
REMANDED
Entitlement to a disability rating in excess of 20 percent for degenerative disc disease of the thoracolumbar spine is remanded.
REASONS FOR REMAND
The Veteran served on active duty from August 1986 to July 1987.  The Veteran originally requested a Board hearing in July 2018, but subsequently withdrew his hearing request in November 2018.  
Entitlement to a disability rating in excess of 20 percent for degenerative disc disease of the thoracolumbar spine is remanded.
The Board observes that since the last December 2015 VA examination of the spine, the Veteran’s statements in his March 2016 substantive appeal indicate a worsening of this disability.  In addition, the VA examinations and VA medical records indicate the Veteran’s back pain causes additional limitation of motion and function, although the VA examinations do not specify where pain began during range of motion testing.  Specifically, a September 2011 VA outpatient treatment report noted severely decreased range of motion with flexion and extension; however, no range of motion testing results were included.  Additionally, the September 2011 VA medical report reflects a positive straight leg raise test, which may indicate some neurological impairment of the lumbar spine.  Therefore, it is necessary to adequately determine the current severity of the Veteran’s thoracolumbar spine disability and the functional effects of such disability.  Snuffer v. Gober, 10 Vet. App. 400 (1997); VAOPCGPREC 11-95 (April 7, 1995); see also 38 C.F.R. § 3.327. 
The matter is REMANDED for the following action:
1. Obtain and associate with the claims file all outstanding pertinent VA and private medical records the Veteran adequately identifies.  
2. Upon receipt of all additional records, schedule the Veteran for a VA examination of the thoracolumbar spine.  The claims folder and a copy of this remand are to be made available to and reviewed by the examiner in connection with the examination.  
The evaluation of the thoracolumbar spine should consist of all necessary testing including range of motion testing for the lumbar spine based on (1) active motion; (2) passive motion; (3) weight-bearing; and (4) non-weight bearing.  If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why this is so. 
The examiner is asked to comment on the following:  
(a).  The degree of severity and the functional effects of the thoracolumbar spine disability on activities of daily living and capacity for work.  
(b).  The degree at which pain begins upon flexion and extension.  
(c).  The extent of any weakened movement, excess fatigability and incoordination.  The examiner should assess the additional functional impairment due to weakened movement, excess fatigability, or incoordination in terms of the degree of additional range of motion loss.
(d).  Whether there would be additional functional impairment on repeated use or during flare-ups.  The examiner should assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss.  If the examination is not conducted during a flare-up, the functional impact of a flare-up should be estimated to include as based on the Veteran’s reports.
(e).  Whether the Veteran has any neurological deficits of the lumbar spine.  
It is essential the examiner provide explanatory rationale for opinions on these determinative issues, citing to specific evidence in the file supporting conclusions.
 
JENNIFER HWA
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Saira Spicknall, Counsel