Citation Nr: 20021558 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 15-20 453 DATE: March 26, 2020 ORDER Entitlement to service connection for residuals, bilateral hand burn injury is granted. REMANDED Entitlement to service connection for a lower back condition to include bilateral lower extremity radiculopathy, claimed as bilateral leg pain, is remanded. Entitlement to service connection for residuals, neck burn injury is remanded. Entitlement to service connection for residuals, face burn injury is remanded. FINDING OF FACT Resolving reasonable doubt in the Veteran’s favor, residuals of a bilateral hand burn injury are at least as likely as not related to an in-service injury and continue to manifest today. CONCLUSION OF LAW The criteria for entitlement to service connection for residuals, bilateral hand burn injury have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the Army from January 1968 to January 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri (Agency of Original Jurisdiction (AOJ)). The Veteran and his wife testified at a video conference hearing before the undersigned in August 2018. A transcript of the proceeding is of record. 1. Entitlement to service connection for residuals, bilateral hand burn injury The Veteran contends that he suffers from bilateral hand burn residuals following an in-service injury. Specifically, he states that during his active duty service in April 1969, he was burned over 20 percent of his body following an accident whereby he caught fire while using a blow torch. He testified that he was not wearing a shirt at the time of the incident and he sustained burns from his waist up to his head, covering both arms. Service treatment records support the Veteran’s testimony alluding to an in-service event. They reveal that in April 1969, he received first and second-degree burns over 20 percent of his body, including his chest, both arms, hands, face, and neck. These burns are further recorded on his Report of Medical History completed at separation, though his separation Report of Medical Examination does not include reference to this incident. Based on the Veteran’s testimony and the corroborating service treatment records, the Board concedes the existence of this in-service event. Furthermore, the Board acknowledges that the Veteran has residual scarring from this incident. The July 2013 VA examination recorded “several very faint, small (1-2 cm at most), irregularly shaped, superficial, nontender, hypopigmented areas rear of the MCP joint of the [right] index finger and web space of [right] thumb, without hair growth within the hypopigmented areas, without induration or redness or contraction or any other visible evidence of prior burn injury.” An August 2018 Disability Benefits Questionnaire (DBQ) similarly documented scarring on the Veteran’s hand as well. As such, the Board finds that the Veteran is entitled to service connection for residuals of a bilateral hand burn injury. REASONS FOR REMAND 1. Entitlement to service connection for a lower back condition to include bilateral lower extremity radiculopathy, claimed as bilateral leg pain, is remanded. At the August 2018 video conference hearing, it was determined that the Veteran’s claim for bilateral leg pain should instead be reclassified as a claim for service connection for a lower back condition to include bilateral lower extremity radiculopathy. He cited an event that took place during his active duty service that he believes caused or contributed to his current lower back and leg condition. Specifically, he contends that in July 1968, he fell approximately 15-20 feet on the ground, landing on his feet. He speculates that, by landing on his feet, the impact compressed his spine and resulted in him experiencing arthritis, requiring subsequent fusion surgery at L5-S1 and C1-C5 for spondylolisthesis. During a VA examination for the Veteran’s legs in April 2015, the examiner documented the Veteran’s account of the in-service event and observed that he was seen at sick call for a right knee problem, but this occurred in February 1967 and was unrelated to any specific injury. This note in his service treatment record also alludes to a back injury that occurred in October 1965, after which subsequent x-rays revealed that the Veteran had a congenital defect. The Board observes that following his August 2018 videoconference hearing, the Veteran obtained a DBQ for his back; however, it does not include an etiology opinion linking it to this or any other in-service event. Similarly, while the prior examination from April 2015 provided an etiology opinion, it pertains to the Veteran’s knee and not his back. It is also critical to determine the nature of the Veteran’s congenital back defect and assess whether it may have been aggravated beyond its natural progression as a result of an in-service injury. As such, the Board must remand for an examination and etiology opinion as it pertains to the Veteran’s back condition and any related lower extremity radiculopathy. 2. Entitlement to service connection for residuals, neck burn injury is remanded. 3. Entitlement to service connection for residuals, face burn injury is remanded. In July 2013, the Veteran received a VA examination for scars; the examiner reported that, by history, the Veteran suffered burns to his face and arms but did not require skin grafts. She did not observe any obvious burn scarring on the Veteran’s face, chest, or arms, or any obvious unilateral thinning of the beard. The Veteran’s August 2018 DBQ similarly noted that he did not have disfigurement of the head, face, or neck. However, the undersigned VLJ was able to see skin discoloring on the Veteran’s face from a distance, and the Veteran testified that he is unable to shave due to the pain caused by the scars on his face and neck. Given that the VLJ was able to see these scars, the Board will remand for an examination performed by a dermatologist to assess the current nature of these scars. The matters are REMANDED for the following action: 1. The AOJ shall associate the Veteran’s most recent outstanding VA medical treatment records with his file, specifically those records from April 2016 to the present. 2. Then, the Veteran should be afforded an appropriate VA examination in order to determine the current nature and etiology of his lower back condition. The claims file must be made available to and be reviewed by the examiner. The examiner should specifically provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such lower back condition and associated bilateral lower extremity radiculopathy occurred in or is otherwise etiologically related to the Veteran’s military service, to include the 3 back injuries described in his October 2013 statement. The examiner is requested to discuss whether there is any medical reason to accept or reject the Veteran’s belief that the mechanism of injuries during service has caused or contributed to his current lumbar spine disability. The examiner should accept as fact that the Veteran has a present lower back condition, to include spondylolisthesis and degenerative disc disease. The examiner should specifically consider the following: • a February 1967 orthopedic consultation prior to entry wherein the Veteran reported a history of back injury in October 1965 and being told that he had a congenital defect; • a February 1967 lumbosacral spine x-ray interpreted as normal; • a September 1969 report of muscular pain of the lower back; • an October 1969 separation examination wherein the Veteran denied recurrent back pain, and examination reflected a normal clinical evaluation of the spine; • accept as true that the Veteran’s October 2013 statement of back injuries during service although not documented; • and an April 2012 private examination noting current radiographic findings of severe degenerative changes at L5-S1, broad-based bulging and severe right foraminal stenosis, and noting that radiographic findings in 2002 showed spondylolisthesis at L5-S1 with stenosis; The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Then, the Veteran should be afforded a VA examination with a dermatologist or similarly qualified specialist in order to determine the current nature of the residuals of his face and neck burn injuries. The claims file must be made available to and be reviewed by the examiner. The examiner should specifically indicate whether the Veteran has residuals of his face and neck burn injuries. The examiner should consider the following: • the Veteran’s service treatment records, documenting the Veteran receiving burns on 20 percent of his body, including his face, neck, and arms; • the lay statements associated with the record in August 2012, referencing the Veteran’s burns; • the Veteran’s lay statement in August 2012, describing the incident that resulted in his burns; • private treatment records associated with the file in February 2013, documenting “spots” on the Veteran’s face; • the Veteran’s lay statement in October 2013 regarding the incident causing his burns; • the April 2015 lay statements regarding the Veteran’s burns; • the Veteran’s VA Form 9 and associated statement; • the August 2018 hearing testimony, specifically the observations of the undersigned that the Veteran appears to have scarring of the face and neck; and • the August 2018 DBQ regarding the Veteran’s scars. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. (continued on the next page) 4. Thereafter, readjudicate the claims. If any benefit sought on appeal remains denied, furnish the Veteran and his representative, if any, a supplemental statement of the case and an appropriate period of time to respond. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Victoria A. Banis, 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.