Citation Nr: 20007975 Decision Date: 01/30/20 Archive Date: 01/30/20 DOCKET NO. 19-17 517 DATE: January 30, 2020 REMANDED A rating in excess of 20 percent for degenerative arthritis of the thoracolumbar spine is remanded. REASONS FOR REMAND The December 2017 VA examination is insufficient to rate the severity of the Veteran’s thoracolumbar spine disability. In the examination report, the examiner reported that there were no neurologic abnormalities or findings related to the thoracolumbar spine. However, in the remarks section at the end of the examination report, the examiner noted “presence of bilateral radiculopathy.” The examination report did not indicate the impacted nerves affected by radiculopathy or the severity sufficient for rating purposes. Under the General Rating Formula for Diseases and Injuries of the Spine, any associated objective neurological abnormalities are to be evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, Note 1. Consequently, on remand, the examiner should identify any associated neurologic impairments due to the thoracolumbar spine disability and provide information sufficient to evaluate them under the rating criteria for nerve disorders. The matter is REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected thoracolumbar spine disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must determine the current severity of any associated objective neurological abnormalities related to the service-connected thoracolumbar spine disability. The examiner should provide a full description of the associated objective neurological abnormalities and report all signs and symptoms necessary for evaluating the associated objective neurological abnormality under the appropriate rating criteria. The examiner must address the findings in the December 2017 VA examination report of the presence of bilateral radiculopathy. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board AD 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.