Citation Nr: 20002803 Decision Date: 01/14/20 Archive Date: 01/13/20 DOCKET NO. 17-51 445 DATE: January 14, 2020 REMANDED Entitlement to service connection for a thoracolumbar spine disorder is remanded. REASONS FOR REMAND The Veteran had active service from November 1972 to November 1974. In January 2018, the Veteran testified before the undersigned Veterans Law Judge. A transcript of that hearing is included in the Veteran’s claims file. The Board of Veterans’ Appeals denied the Veteran’s claim in a September 2018 decision. He perfected an appeal of that decision to the U.S. Court of Appeals for Veterans Claims (the Court). In June 2019, the Court entered a Joint Motion for Remand that vacated the Board’s September 2018 decision and remanded it for further action. The Veteran’s appeal is once again before the Board. For the reasons stated below, the Board remands the issue on appeal. Entitlement to Service Connection for a Thoracolumbar Spine Disorder Is Remanded The Veteran contends that his current thoracolumbar spine disorder—diagnosed as intravertebral disk syndrome, degenerative disk disease, and spinal stenosis of the lumbar spine—is due to a March 1973 stab wound he suffered during active service. The Veteran also incurred an April 1974 low back strain during active service. According to the Veteran’s January 2018 hearing testimony and an October 2015 statement, his stab wound did not resolve during active service, and he has suffered back pain since his separation from active service. The Board concludes that the evidence of record indicates that there may be a nexus between the Veteran’s thoracolumbar spine disorder and his active service; however, the evidence of record is inadequate to adjudicate the Veteran’s claim. See 38 U.S.C. § 5103A (d)(2)(B); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (“fulfillment of the statutory duty to assist here includes the conduct of a thorough and contemporaneous medical examination.”). February 2013 magnetic resonance imaging (MRI) examinations document DDD and spinal stenosis of the lumbar spine. A January 2017 contracted VA examination documents additional diagnoses of IVDS and mild radiculopathy of the right lower extremity. The Veteran’s service treatment records show that he was treated for a stab wound in March 1973. However, the evidence of record is inadequate to determine whether the Veteran’s thoracolumbar spine disorder is due to the March 1973 stab wound. The Board notes an August 2018 letter, Dr. S.F., an internist with a VA medical center who has treated the Veteran concluded that his thoracolumbar spine disorders and associated radiculopathy of the right lower extremity were at least as likely as not due to March 1973 stab wound. According to Dr. S.F., the penetrating wound could have possibly contributed to paraspinal muscle weakness that negatively affected the Veteran’s lumbar spine over the years and resulted in the degenerative changes, including loss of disk height, sclerotic changes and osteophyte formation. He also indicated that it was possible that the stab wound injury contributed to the Veteran’s chronic low back pain. Dr. S.F.’s opinion is stated in equivocal language, undermining its value in determining the etiology of the Veteran’s current thoracolumbar spine disability. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (2014); Owens v. Brown, 7 Vet. App. 429, 433 (1995). While the Veteran received a VA examination in January 2017, the examiner did not have the opportunity to review Dr. S.F.’s opinion. The Veteran’s statements regarding back pain that persisted after the March 1973 stabbing and continued after his separation form active service were also not addressed. Moreover, the examiner did not address whether the Veteran suffered from the disability of back pain that causes functional loss continuously since service, and whether it was caused by his in-service stab wound and residuals. In light of the above, the Veteran must be afforded a new examination to adjudicate his claim of entitlement to service connection for a thoracolumbar spine disorder. See 38 U.S.C. § 5103A(d)(2)(B); McLendon, 20 Vet App. at 83; Green, 1 Vet. App. at 124. The matters are REMANDED for the following action: Schedule the Veteran for an examination to determine the nature and etiology of any chronic disability of the thoracolumbar spine. Following a review of the claims file and examination, the examiner should address the following: a. Identify/diagnose any disability of the thoracolumbar spine that presently exists or that has existed during the appeal period. It is noted that pain resulting in functional impairment may constitute a disability for service-connection purposes. So, the examiner is to specifically state whether there is any functional impairment associated with the Veteran’s complaints of pain. The “Functional Impact” section of the report of examination should be completed. If there is/was not functional impairment, explain why. b. For any identified disability of the lumbar spine or functional impairment due to pain, the clinician should state whether the disorder is at least as likely as not related an in-service event, disease or injury, to include a March 1973 stab wound and an April 1974 low back strain. In rendering the opinion, the examiner should address the question of whether the Veteran has suffered from the disability of back pain that causes functional loss continuously since service, and whether it was caused by his in-service stab wound and residuals. Consideration must be given to the August 2018 opinion from Dr. S.F. as well as the Veteran’s statements of regarding continuous back pain following his separation form active service. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Douglas M. Humphrey, 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.