Citation Nr: 19166239 Decision Date: 08/27/19 Archive Date: 08/27/19 DOCKET NO. 14-13 303 DATE: August 27, 2019 REMANDED The issue of service connection for a lumbar spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1962 to May 1965. This matter comes before the Board of Veterans’ Appeals (Board) from a December 2012 rating decision. In September 2015, the Board remanded the appeal to the agency of original jurisdiction (AOJ) for additional development. In February 2018, the Board denied the service connection claim for a lumbar spine disability. The Veteran appealed the Board’s decision regarding service connection for a lumbar spine disability to the Court of Appeals for Veterans Claims (Court). In a December 2018 Order, the Court granted a Joint Motion for Remand (Joint Motion), vacating the February 2018 Board decision and remanding for additional proceedings. The issue of service connection for a lumbar spine disability is remanded. An August 2010 private treatment record from C. Smith, D.O., confirmed on x-ray examination a current lumbar spine degenerative arthritis at L5-S1 with diffuse osteoarthritic changes throughout the lower lumbar spine. The record also notes that Dr. Smith had last seen the Veteran for back problems in 1998. The Veteran contends that his current lumbar spine disability began in service or is related to back pain he experienced during service. Service treatment records reflect his spine was documented as normal on enlistment examination in April 1962; however, in August 1962, he complained of back problems, describing chronic lumbar pain on certain motions for the prior two years with his present difficulty becoming worse in the prior week. In September 1962, he reported he “throws out [his] back now and then,” and described pain in the right paraspinal area and right flank when lifting or bending. The diagnosis was “neg[ative]–no muscle spasm or tenderness.” He was referred to the orthopedic clinic. A September 1962 orthopedic clinic note indicates the examiner found “nothing on [physical examination] or on x-ray. A lumbar spine x-ray report noted the Veteran’s history of back pain with no history of trauma. The x-ray report was reported as negative; an incidental finding noted spleen calcification was present. The orthopedic examiner concluded the Veteran “probably [had a] minor sprain with some psychosomatic fixation.” No treatment was ordered. In a March 1965 separation report of medical history, the Veteran denied currently or ever having arthritis or rheumatism; swollen or painful joints; bone, joint, or other deformity; or having even worn a back brace or support. On separation examination the same day, his spine was reported as normal on clinical evaluation. The Veteran reports that the back pain he experienced in service has continued and progressed since separation from military service. The parties to the Joint Motion agreed that the Board failed to make reasonable efforts to obtain outstanding relevant treatment records. Specifically, the parties agreed that VA failed in its duty to assist the Veteran by not requesting the 1998 treatment record referenced by the August 2010 record authored by Dr. Smith. Accordingly, the appeal must be remanded to obtain outstanding treatment records and to obtain a supplemental medical opinion. The matter is REMANDED for the following action: 1. With any necessary assistance from the Veteran, obtain the following records: a) All treatment records from C. Smith, D.O., since establishing medical care, including the report of a 1998 record in which the Veteran was evaluated and treated with an injection for back pain; and (Continued on the next page)   b) All treatment records from the Kansas City VA Medical Center (VAMC) since establishing care but prior to January 2012, and all records dating since May 2012. 2. After the outstanding treatment records are obtained, provide the Veteran’s entire electronic claims file to the November 2015 VA examiner, or to another appropriate clinician, to obtain an addendum medical opinion as to the etiology of the current lumbar spine degenerative arthritis at L5-S1 with diffuse osteoarthritic changes throughout the lower lumbar spine. Following a review of the claims file, the reviewing examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the current lumbar spine disability (a) had its onset in service; (b) manifested to a compensable degree within one year of separation from service; or (c) is otherwise medically related to service, including the evaluation for back problems in August and September 1962. A complete medical rationale must be provided for all opinions expressed. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Kirscher Strauss, 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.