Citation Nr: 18136289 Decision Date: 09/18/18 Archive Date: 09/18/18 DOCKET NO. 10-23 599 DATE: September 18, 2018 REMANDED The issue of a rating in excess of 40 percent for the Veteran’s lumbosacral spine degenerative disc disease with lumbar spine laminectomy residuals is remanded. The issue of entitlement to a total rating for compensation purposes based on individual unemployability due to service connected disabilities (TDIU) for the period prior to June 1, 2015 is remanded. REASONS FOR REMAND The Veteran had active service from February 2002 to August 2003. In June 2016, the Board of Veterans’ Appeals (Board) granted a TDIU for the period on and after June 1, 2015 and remanded the issues of an increased rating for the service connected lumbosacral spine disability and a TDIU for the period prior to June 1, 2015 to the Agency of Original Jurisdiction for additional development of the record. 1. The issue of a rating in excess of 40 percent for the Veteran’s lumbosacral spine degenerative disc disease and lumbar spine laminectomy residuals is remanded. The Veteran was last afforded a Department of Veterans Affairs (VA) spine examination in October 2015. The VA examination report notes that the Veteran exhibited a lumbosacral spine range of motion of forward flexion to 45 degrees; extension to 0 degrees; lateral flexion to 20 degrees, bilaterally; and lateral rotation to 0 degrees, bilateral. The examiner commented that the Veteran exhibited pain on forward flexion, extension, lateral flexion, and lateral rotation of the lumbosacral spine and “pain noted on exam and causes functional loss.” The Board observes that the VA examiner failed to report at what degree/point on range of motion testing that the Veteran’s lumbosacral spine pain began. VA’s duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Given the cited deficiencies in the October 2015 VA spine examination report and the passage of several years, the Board concludes that further VA spine evaluation is needed to adequately address the issues raised by the Veteran’s appeal. This examination should also comply with Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017) Clinical documentation dated after June 2018 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran’s claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 2. The issue of entitlement to a TDIU for the period prior to June 1, 2015, is remanded. Entitlement to TDIU requires an accurate assessment of the impairment associated with all of the service-connected disabilities. As the claim for TDIU is inextricably intertwined with the other claim being remanded, the issue of entitlement to TDIU for the period prior to June 1, 2015, must also be remanded. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated him for the service connected lumbosacral spine disability. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records dated after June 2018. 3. Schedule the Veteran for a VA spine examination to assist in determining the current severity of the service connected lumbosacral spine disability. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Provide ranges of motion for passive and active motion of the lumbosacral spine. The examiner should state whether there is any additional loss of lumbosacral spine function due to painful motion, weakened motion, excess motion, fatigability, or incoordination. (b) Indicate whether, and to what extent, the Veteran experiences functional loss of the spine due to pain or any other symptoms during flare ups or with repeated use. The examiner should obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flare-ups from the Veteran. The examiner should elicit relevant information as to the Veteran’s flares with a description of the additional functional loss, if any, the Veteran has during flares. The examiner should estimate the Veteran’s functional loss due to flares based on all the evidence of record-including the lay information or sufficiently explain why the examiner cannot do so. (c) Note any incapacitating episodes associated with the lumbosacral spine disability. An incapacitating episode is a period of acute signs and symptoms that requires bed rest prescribed by a physician and treatment by a physician. (d) Specifically address the impact of the lumbosacral spine disabilities on the Veteran’s vocational pursuits for the period prior to June 1, 2015. J. CONNOLLY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. T. Hutcheson, Counsel