Citation Nr: 20021256 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 17-19 918 DATE: March 25, 2020 REMANDED Service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1965 to June 1969. This matter originally came before the Board of Veterans’ Appeals (Board) from an August 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in White River Junction, Vermont. This matter has been previous remanded for further development in October 2019. The matter is again before the Board. This matter has been advanced on the docket pursuant to 38 C.F.R. § 20.902(c). Service connection for a low back disability is remanded. The Veteran believes that service connection for a low back disability is warranted. See NOD. The Veteran underwent a VA examination for the low back in December 2019. The examination found that the Veteran’s low back disabilities were not related to service. The Board finds the December 2019 VA examination inadequate because it did not consider all the relevant evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Specifically, the examination did not consider the Veteran’s report that an in-service low back injury started the deterioration of discs, which resulted in two back surgeries and the current low back and leg pain the Veteran was experiencing. See NOD. Additionally, the examination did not consider the Veteran’s report that the low back symptoms began with the in-service low back injury and have continued since then until now and have worsened. See VA 646. Because the examination did not consider all the relevant evidence of record, including the Veteran’s report of continuity of symptomatology, the Board finds the December 2019 VA examination inadequate and a remand is needed for a new VA examination. The matter is REMANDED for the following action: 1. Update VA and private treatment records. VA treatment records appear current up to January 2020. 2. Schedule the Veteran for an appropriate VA examination for the low back. The need for an in-person examination of the Veteran is left to the discretion of the examiner. Following a review of the claims file and a copy of this Remand, the examiner is requested to furnish an opinion with respect to the following: (A) Provide all diagnoses of the Veteran’s low back existing at any point during the pendency of the appeal (i.e. since December 2013), even if they are currently asymptomatic or have resolved during the pendency of the appeal. (B) For each diagnosis, is it at least as likely as not (a 50 percent probability or greater) that the low back disability is related to the Veteran’s service? This includes, but is not limited to, the in-service incident when the Veteran was thrown into the handmade pool on his back and conceded herbicide agent exposure. (C) Is it at least as likely as not (a 50 percent probability or greater) that the degenerative disc disease manifested to a compensable degree within one year following the Veteran’s service? In rendering these opinions, the examiner is asked to consider the following evidence in addition to the other relevant evidence of record: (1) The Veteran’s report that his back was injured during an initiation for crossing the equator during service. The Veteran was tossed into a man-made pool on the flight deck and landed on his back. He was later diagnosed with spinal fusion for a ruptured lumbar disc, lumbar discectomy, and degenerative disc disease. The Veteran believes that service caused the current back condition. See February 2020 Appellate Brief. (2) Medical records from 2007 to 2020 showing consistent complaints of low back pain over the years. See January 2020 CAPRI. (3) Medical records from 2019 showing that the Veteran reported a back injury during service, had a history of a lumbar diskectomy in 1989 and a spinal fusion in 1991, and an impression of posterior fusion L5-S1, degenerative disc disease. Id. (4) Medical records from 2014 showing the belief that the Veteran had a sciatic nerve pinch. Id. (5) A medical record from 2019 recounting the in-service initiation injury. See December 2019 C&P Exam. (6) The Veteran’s report of initially injuring his back during a shellback initiation ceremony during service and that the symptoms have continued to exist since that time and have worsened. See April 2017 VA 646. (7) The Veteran’s report of being thrown into a handmade pool on the flight deck, resulting in a low back injury. This started the deterioration of discs, resulting in two back surgeries and the current low back and leg pain connected to the L-1 disc. See NOD. (8) Any and all other relevant lay and medical evidence. A complete rationale for all opinions offered should be provided. Address the Veteran’s documented history and assertions. The examiner must address the Veteran’s reports of continuity of symptomatology since service. All necessary tests and studies should be conducted. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner should provide an explanation stating why. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is due to the limits of the medical community or the limits of the examiner’s medical knowledge.   The examiner is reminded that the Veteran is competent to attest to factual matters of which the Veteran has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. 3. Readjudicate the issue on appeal. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Dougan 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.