Citation Nr: 20040109
Decision Date: 06/11/20	Archive Date: 06/11/20

DOCKET NO. 18-36 925
DATE: June 11, 2020

REMANDED

Entitlement to service connection for a lumbar spine disorder is remanded.

REASONS FOR REMAND

The Veteran had active service from August 1951 to April 1954.  In connection with this appeal, the Veteran testified at a hearing before the undersigned in December 2012.  A transcript of that hearing is of record.

This case has been advanced on the Board’s docket.

The Veteran asserts that his lumbar spine disorder is due to his active service.  At the December 2019 Board hearing, the Veteran testified that he entered service at 17 years of age and that prior ot his active service, he had no back problems.  He further testified that he was required to perform heavy work, which resulted in his current back problems.

The Veteran’s STRs show that at an August 1951 physical, he had normal examinations of his spine.  In April 1954, he reported that he had chronic back pain for four to five years.  An x-ray of his thoracic spine showed compression compatible with a diagnosis of Scheuermann’s disease.  An x-ray of his lumbar spine was negative.  He was diagnosed with osteochondritis.  An April 1954 Medical Review Board determined that the Veteran was not considered physically qualified for military duty.

The Veteran was afforded a VA examination for his lumbar spine in July 2017.  Unfortunately, the VA examiner reported that he did not have access the Veteran’s claims file for review, and as such, did not provide an opinion on etiology.  In February 2020, the Board remanded the claim for further development, to include a new VA examination.  Unfortunately, the Veteran failed to report to the schedule VA examination in March 2020.

As such, a remand is necessary to adjudicate the service connection claim for a lumbar spine disorder in order to obtain a medical opinion.  

The matters are REMANDED for the following action:

1. Obtain a medical opinion to address the nature and etiology of any current lumbar spine disorder.  Only if an opinion cannot be provided without a physical examination should the AOJ arrange for a physical examination.  The VA examiner should provide the following opinions:

a. Is it at least as likely as not (50 percent or greater) that any lumbar spine disorder clearly and unmistakably existed prior to the Veteran’s active service?  Why or why not?

The examiner should discuss the Veteran’s STRs showing thoracic spine compression compatible with a diagnosis of Scheuermann’s disease and a diagnosis of osteochondritis.  The examiner should also discuss the Veteran’s lay statements regarding the onset of his lumbar spine disorder due to his age and performing heavy work.

b. If a lumbar spine disorder did clearly and unmistakably exist prior to active duty service, provide an opinion as to whether the pre-existing lumbar spine disorder clearly and unmistakably (obviously, manifestly, and undebatable) was not aggravated (meaning the underlying disability increased in severity beyond the natural progression of the disability) during his active duty service.  Why or why not?

c. If a lumbar spine disorder did not clearly and unmistakably exist prior to active duty service, provide an opinion whether it is as least as likely as not (50 percent probability or greater) that any lumbar spine disorder either began during or was otherwise caused by his active service?  Why or why not?

 

 

Thomas H. O'Shay

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	T. Berryman, 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.