Citation Nr: 19152004
Decision Date: 07/03/19	Archive Date: 07/03/19

DOCKET NO. 16-53 678
DATE:	July 3, 2019

REMANDED

Entitlement to service connection for a cervical spine disorder is remanded.

Entitlement to service connection for a thoracolumbar spine disorder is remanded.

REASONS FOR REMAND

The Veteran served on active duty from December 1986 to August 2010.

1. Entitlement to service connection for a cervical spine disorder is remanded.

2. Entitlement to service connection for a thoracolumbar spine disorder is remanded.

The Board cannot make a fully-informed decision on the issues of entitlement to service connection for cervical spine and thoracolumbar spine disorders because no VA examiner has adequately addressed in-service treatment records reflecting treatment for neck and back injuries or current neck and back disorders.

The matters are REMANDED for the following action:

1. Obtain VA treatment records since January 2017 and associate them with the claims file.

2. Schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any diagnosed cervical and thoracolumbar spine disorders.  The examiner should address the following questions: following questions:

(a) Is it at least as likely as not (i.e., probability of 50 percent or greater) that any diagnosed cervical spine disorder began in service, was caused by service, or is otherwise etiologically related to active duty service?

(b) Is it at least as likely as not (i.e., probability of 50 percent or greater) that any diagnosed thoracolumbar spine disorder began in service, was caused by service, or is otherwise etiologically related to active duty service?

In answering these questions, the examiner should address the following:

•	Service treatment records reflecting treatment for cervical and thoracolumbar issues, including November 1999 service treatment records reflecting “minimal spondylosis” in the spine and L4-L5 facet dysfunction (see also October 1999, May 1996, June 1996, October 1991 Service Treatment Records);

•	December 2013 VA examination reflecting spine changes consistent with aging but indicating insufficient information to provide an opinion; 

•	June 2018 private medical records reflecting chronic and discogenic back pain; and

•	the Veteran’s March 2019 testimony that issues with his cervical and thoracolumbar spine began during in-service injuries reflected in the service treatment records and have continued since that time.

The examiner is requested to discuss whether there is any medical reason to accept or reject the Veteran’s belief that his cervical and thoracolumbar spine pain results from trauma incurred during in-service incidents reflected in his service treatment records.  Additionally, the examiner is requested to discuss whether the November 1999 chest x-ray referring to “[m]inimal spondylosis is present in the spine” referred to the cervical and/or thoracolumbar spine.  A complete rationale must be provided for the opinion.

 

T. MAINELLI

Veterans Law Judge

Board of Veterans’ Appeals

ATTORNEY FOR THE BOARD	C. Howell, Associate Counsel

The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.