Citation Nr: 19167167 Decision Date: 08/29/19 Archive Date: 08/28/19 DOCKET NO. 19-14 559 DATE: August 29, 2019 REMANDED Entitlement to service connection for a lumbar spine disorder, to include a neurological disorder, is remanded. REASONS FOR REMAND The Veteran had active duty service from September 1975 to September 1979 and from December 1982 to November 1988. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a December 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for a lumbar spine disorder, to include a neurological disorder, is remanded. Evidence indicates that there may be outstanding relevant VA treatment records. In an April 2019 statement, the Veteran reported that, since VA last acquired the Veteran's VA treatment records, he has continued to receive VA treatment for the disability on appeal. Any VA treatment records are within VA’s constructive possession, and are considered potentially relevant to the issue on appeal. A remand is required to allow VA to obtain them. The Veteran filed a claim for service connection for residuals of in-service low back injuries noted in his service medical records. Recent VA treatment records indicate treatment for low back pain. In a November 2017 VA examination report and medical opinion, a VA examiner diagnosed degenerative joint disease of the lumbar spine and opined that the disability was not related to service. In both October 2018 testimony before a VA Decision Review Officer and an April 2019 statement, the Veteran indicated that he was seeking service connection for neurological pain he believed to be unrelated to the diagnosed lumbar degenerative arthritis. The Veteran stated that his VA physician had advised him that he was experiencing pain due to nerves that would occasionally interact with his spine rather than arthritis. The Veteran stated that he had experienced episodes of such pain since service. In support of his contentions, the Veteran submitted a copy of a September 2018 VA MRI report, reporting the current state of the lumbar spine and adjacent nerves. The Board notes that the November 2017 VA examiner did not have the opportunity to review the September 2018 VA MRI report prior to writing the most recent VA examination report and medical opinion. Based on the Veteran's contentions and the additional evidence added to the claims file, a remand is necessary to schedule an additional examination to determine the nature and etiology of the Veteran's claimed lumbar spine disorder. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from February 2018 to the Present. 2. Schedule the Veteran for an examination by a VA medical doctor examiner to determine the nature and etiology of any lumbar spine disorder, to include both orthopedic and neurological disabilities. The examiner should review the record, to include the service medical records, indicating treatment for low back pain; the post-service medical records, to include those noting treatment for low back pain and the September 2018 VA MRI report; the November 2017 VA medical examination and opinion; and the Veteran's lay statements, to include his October 2018 testimony before a VA Decision Review Officer and his April 2019 statement, included with his VA Form 9 (Substantive Appeal to the Board). Having reviewed the file, interviewed the Veteran, and performed an examination, the examiner must opine whether any diagnosed lumbar spine disorder, to include both orthopedic and neurological disabilities, is at least as likely as not related to an in-service injury, event, or disease. The examiner should consider the Veteran’s February 1976 complaints of back pain after falling or almost falling from a top rack, the June 1985 complaints of low back pain and the August 1988 complaints of back pain after turning incorrectly at desk. Regarding any diagnosed arthritis conditions or diagnosed organic diseases of the nervous system, the examiner should also opine as to whether any diagnosed disease at least as likely as not (1) began during active service, (2) manifested within one year after the date of discharge from either of the Veteran's periods of active service (i.e., September 1979 and November 1988), or (3) was noted during service with continuity of the same symptomatology since service. KRISTY L. ZADORA Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T.M. Gillett, 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.